lia 


ILLUSTRATIONS 


OF  THE 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN 

IN  THE  INSANE 


A  SELECTION  OF  SEVENTY-FIVE  PLATES  SHOWING  THE  PATHOLOGICAL 

CONDITIONS  FOUND  IN  POST-MORTEM  EXAMINATIONS 

OF  THE  BRAIN  IN  MENTAL  DISEASES 


I.   W.   BLACKBURN,   M.   D. 

Pathologist  to  the  Government  Hospital  for  the  Insane,  Washington,  /'.  C;  Professor  of 

Morbid  Anatomy  in  the  Medical  Department  of  the  University  oj  Georgetovm, 

anil  in  the  Department  of  Medicine  of  the  George  Washington 

University,  Washington,  IK  C. 


WASHINGTON 

GOVERNMENT     PRINTING     OFFICE 

19  0  8 


Biomedical 
Library 

WL 

3oo 

nor 


CONTEXTS. 


1 


Page. 

Letters  of  transmittal %  1L 

Introduction 

Arteriosclerosis  and  other  vascular  conditions *> 

Arteriosclerotic  cerebral  softenings 

Hemorrhages 4° 

Atrophy  of  the  brain °" 

Meningoencephalitis — Paresis 

Hydrocephalic  states 

Meningeal  conditions 

Cerebral  compressions 1"° 

Sclerotic  conditions l'1- 

Intracranial  and  brain  tumors I"18 

urn 


86 
92 


7S2642 


ILLUSTRATIONS. 


Page. 

Plate   I.  Dissection  of  the  basal  arteries  in  arteriosclerosis 6 

II.  Dissection  of  the  cerebral  arteries  in  arteriosclerosis 

III.  The  arteries  at  the  base  of  the  brain  in  advanced  calcareous  arteriosclerosis 10 

IV.  A  dissection  of  the  sclerotic-  arteries  of  the  mesial  surface  ami  the  insula,  etc 12 

V.  Dissection  of  the  cerebral  arteries,  showing  an  anomalous  circle  of  Willis,  etc 11 

VI.   Aneurisms  of  the  basal  arteries  and  an  anomalous  anterior  choroid  artery  of  the  lefl  side 16 

VII.  The  base  of  the  brain  showing  arteriosclerosis  and  anomalous  arteries Is 

VIII.  The  base  of  a  brain  showing  arteriosclerosis 20 

IX.  The  base  of  the  brain  showing  arteriosclerosis  of  the  small  vessel  type 22 

X.  The  base  of  a  brain  showing  arteriosclerosis -I 

XI.   Dissection  showing  the  distribution  of  the  anterior  cerebral  arteries  and  the  distribution  of  a 

large  median  anterii >r  eerel iral  art ery -' ' 

XII.  A  large  arteriosclerotic  softening  of  the  left  hemisphere 28 

XIII.  A  large  arteriosclerotic  softening  of  the  left  hemisphere :'0 

XIV.  Left  half  of  brain  with  multiple  cortical  softenings  due  to  arteriosclerosis 32 

XV.  The  base  of  the  brain  showing  arteriosclerosis  of  the  basal  vessels  and  softening  from  obstruc- 
tion of  the  right  posterior  cerebral  artery :'4 

XVI.  A  horizontal  section  of  a  brain  showing  central  softenings  from  arteriosclerosis 36 

XVII.  A  horizontal  section  of  a  brain  showing  central  arteriosclerotic  softenings 38 

XVIII.  A  horizontal  section  of  a  brain  showing  syphilitic  softenings  of  the  interior  and  the  cortex..  40 

XIX.  Horizontal  section  of  a  brain  showing  cicatricial  central  softenings 42 

XX.  The  superior  aspect  of  the  brain  in  a  case  of  thrombotic  softening  affecting  the  whole  left  hemi- 
sphere   ** 

XXI.  Arteriosclerotic  softenings  of  cerebrum 46 

XXII.  A  brain  the  seat  of  a  large  hemorrhage  causing  left  hemiplegia 48 

XXIII.  A  horizontal  section  of  a  brain  showing  hemorrhage  in  the  right  basal  ganglia 50 

XXIV.  Cerebral  hemorrhage  destroying  the  right  internal  capsule  and  the  nucleus  lentiformis 52 

XXV.   Horizontal  section  of  a  brain  which  had  been  the  seat  of  a  hemorrhage 54 

XXVI.  Horizontal  section  of  a  brain  showing  the  effects  of  a  former  hemorrhage 515 

XXVII.  The  left  hemisphere  in  a  case  of  extreme  cerebral  atrophy 58 

XXVIII.  The  superior  surface  of  a  brain  from  a  case  of  senile  dementia  with  numerous  cortical  soften- 
ings due  to  arteriosclerosis I,(1 

XXIX.  Extreme  atrophy  of  frontal  regions  of  the  brain '■- 

XXX.  The  superior  surface  of  the  cerebrum,  showing  atrophy:  the  fissures  are  artificially  separated  ...  64 

XXXI.  The  superior  surface  of  a  brain  in  chronic  dementia  with  cerebral  atrophy 66 

XXXII.  The  superior  aspect  of  the  brain  in  a  case  of  chronic  dementia  with  atrophy 68 

XXXIII.  Mesial  surface  of  the  right  hemiencephalon  in  chronic  melancholia 70 

XXXIV.  Superior  surface  of  the  brain  showing  arteriosclerotic  devastations  of  the  cortex ~- 

XXXV.  A  dissection  showing  the  basal  arteries  and  the  atrophy  of  the  brain  in  the  region  of  the  insula-.  74 

XXXVI.  Horizontal  section  of  a  brain  from  a  case  of  senile  dementia ■•' 

XXXVII.  A  horizontal  section  of  a  brain  of  syphilitic  dementia s 

XXXVIII.   Brain  of  a  case  of  senile  dementia  in  a  patient  aged  99  years 

XXXIX.  Lateral  surface  of  the  left  hemiencephalon  in  a  case  of  chronic  melancholia.... 

XL.  The  superior  surface  of  the  lira  in  in  chronic  mania M 

Xl.I.   The  effects  of  re val  of  the  pia  in  paresis 

v 


yj  ILLUSTRATIONS. 

Page. 

Plate  XLII.  The  left  hemisphere  in  a  case  of  paresis  with  flaking  of  the  cortex 88 

XLIII.  The  right  hemiencephalon  in  a  case  of  paresis !,° 

XLIV.   Brain  showing  chronic  internal  hydrocephalus « 

XLV.  Chronic  acquired  internal  hydrocephalus 94 

XLVI.  Chronic  acquired  internal  hydrocephalus w> 

XLVII.  A  case  of  chronic  acquired  circumscribed  internal  hydrocephalus 98 

XLVIII.  Transverse  section  of  the  brain  showing  chronic  internal  hydrocephalus,  probably  congenital .  100 

XLIX.  Horizontal  section  of  a  brain  from  a  case  of  senile  dementia  with  ventricular  dilatation 102 

L.  A  case  of  chronic  congenital  internal  hydrocephalus 104 

LI.  A  case  of  chronic  congenital  internal  hydrocephalus.     Interior  of  basal  portion 106 

LII.  A  case  of  chronic  congenital  internal  hydrocephalus.     Interior  of  upper  portion 108 

LIII.  Superior  surface  of  a  brain  showing  leptomeningitis 110 

LIV.  The  inferior  surface  of  a  brain  showing  leptomeningitis 112 

LV.  A  brain  showing  chronic  meningeal  thickening  and  atrophy  consequent  upon  bullet  wound  of 

the  head m 

LVI.  The  right  hemiencephalon  from  a  case  of  acute  mania 116 

LVII.  The  superior  aspect  of  the  brain  in  a  case  of  extreme  meningeal  hyperemia  with  chronic 

oedema 

LVIII.  The  superior  aspect  of  a  brain  from  a  case  of  extreme  atrophy  in  the  terminal  dementia  of  mel- 
ancholia   120 

LIX.  Superior  surface  of  the  brain  showing  engorgement  of  the  pial  veins 122 

LX.  View  of  the  brain  in  a  case  of  meningo-encephalitisof  childhood,  with  arrest  of  development  of 

the  brain.     Photographed  with  a  brain  of  normal  size  and  weight 124 

LXI.  Views  of  the  brain  in  a  case  of  meningo-encephalitisof  childhood,  with  arrest  of  development  of 

the  brain '  -'' 

LXII.  The  superior  surface  of  a  brain  compressed  by  accumulation  of  subdural  fluid 128 

LXIII.  The  superior  aspect  of  a  brain  showing  compression  of  the  left  hemisphere  by  a  hematoma  of 

the  dura ' :,° 

LXIV.  Right  hemisphere  of  a  case  of  atrophic  sclerosis  in  epilepsy 132 

LXV.  The  superior  surface  of  a  brain  with  localized  sclerosis  of  the  left  frontal  lobe 134 

LXVI.  A  case  of  sclerosis  of  a  portion  of  the  right  hemisphere  in  epilepsy 136 

LXVII.  Sclerosis  of  a  portion  of  the  right  hemisphere  in  epilepsy 138 

LXVIII.  Mesial  view  of  the  left  hemisphere  showing  absence  of  the  septum  pellucidum 140 

LXIX.  Horizontal  section  of  a  brain  without  a  septum  pellucidum 142 

LXX.  Horizontal  section  of  a  brain  made  on  a  level  with  the  junction  of  the  fornix  with  the  callosum .       144 

LXXI.  Horizontal  section  of  a  brain  from  a  case  of  dementia  prsecox 146 

LXXII.  Section  of  brain  showing  glioma  of  the  left  frontal  lobe 148 

I,X  XIII.  Plate  showing  a  tumor  of  the  dura  penetrating  the  brain 150 

I, XXIV.  Mesial  surface  of  the  left  hemiencephalon,  showing  cavity  left  in  the  brain  after  enucleation 

of  the  tumor  of  the  dura  shown  on  Plate  LXXIII I52 

LXXV.  Tumor  of  the  dura  penetrating  the  brain 154 


LETTERS  OF  TRANSMITTAL. 


Government  Hospital  for  the  Insane, 

Washington,  />.  <'.,  June  11.  1908. 
Sir:  I  have  the  honor  to  transmit  herewith,  for  publication,  a  work  on  the  Gross  Morbid 
Anatomy  of  the  Brain  in  the  Insane,  prepared  by  Dr.  I.  W.  Blackburn,  pathologist  to  this  hospital. 
Very  respectfully, 

Wm.  A.  White, 

Superintendt  nt. 
The  Secretary  of  the  Interior. 

Government  Hospital  for  the  Insane, 

Washington,  D.  C,  June  11,  1908. 
Sir:  I  have  the  honor  to  submit  to  you  the  work  on  the  Gross  Morbid  Anatomy  of  the 
Brain  in  the  Insane,  prepared  under  your  permission  and  direction.  The  work  consists  of 
75  plates  illustrating  the  pathological  conditions  met  with  in  post-mortem  examinations  of 
the  brain  in  the  insane,  together  with  a  brief  descriptive  text  and  an  introduction.  The  plates 
are  selected  from  the  photographs  of  pathological  subjects  which  form  the  hospital  collection, 
now  numbering  several  hundred. 

Trusting  that  the  work  may  meet  with  your  approval,  and  with  sincere  thanks  for  your 
assistance  and  support,  I  am, 
Very  respectfully, 

I.  W.  Blackburn,  M.  D., 

Pathologist. 

Dr.  William  A.  White, 

Superintendent  Government  Hospital  for  the  Insane. 

(VII) 


GROSS  MORBID  ANATOMY  OF  THE  BRAIN   IX  THE  INSANE 


By  I.  W.  Blackburn,  M.  D. 


INTRODUCTION. 

In  the  preparation  of  this  work  the  aim  has  been  to  furnish  accurate  photographic  represen- 
tations of  the  gross  changes  which  may  be  met  with  in  post-mortem  examinations  of  the  brains 
of  the  insane.  Comparatively  few  general  practitioners  of  medicine  have  any  degree  of  famil- 
iarity with  the  common  pathological  conditions  affecting  the  brains  of  the  insane,  and  to  this 
class  the  work  will  appeal  rather  than  to  the  neuro-pathologist. 

Fresh  specimens — or  the  next  best,  museum  specimens — are  not  easily  accessible;  therefore 
the  representations  of  these  pathological  conditions  by  photography  and  by  photographic  repro- 
ductions seems  to  be  the  natural  means  which  suggests  itself,  and  the  present  work  is  an  effort 
in  that  direction.  The  ideal  way  to  represent  pictorially  the  gross  appearances  of  a  specimen 
is  to  accurately  color  the  picture  after  nature,  which  requires  high  artistic  skill  and  great  expendi- 
ture of  time,  while  the  cost  of  reproduction  in  color  precludes  this  method.  Fortunately,  many 
of  the  gross  changes  in  the  brain  are  morphological,  and  depend  little  upon  color;  such  are  well 
shown  in  black  and  white. 

The  technical  difficulties  in  preparing  the  photographs  were  many,  and  only  overcome,  at 
least  in  a  measure,  by  many  trials  and  much  laborious  effort.  It  was  finally  concluded  that 
the  best  method  was  to  partly  fix  or  harden  the  specimen,  usually  in  formalin,  place  it  momen- 
tarily in  alcohol,  and,  after  allowing  the  surface  to  dry  to  prevent  glistening,  to  photograph  it 
directly  by  means  of  a  vertical  camera.  Fresh  specimens  containing  much  blood,  or  those 
which  have  preserved  their  color  in  Kaiserling,  do  not  photograph  so  well,  as  even  with  ortho- 
chromatic  plates  the  reds  and  yellows  take  too  dark  and  the  details  are  obscure.  After  the 
photograph  is  made,  if  satisfactory,  it  is  ready  for  reproduction;  if  details  require  to  be  elabo- 
rated, a  bromide  enlargement  is  made  on  crayon  paper,  and  on  this  the  artist  works,  having  con- 
stant reference  to  the  museum  specimen  as  a  guide  to  his  work.  The  bromide  picture  is  then 
rephotographed  for  reproduction  by  any  of  the  mechanical  processes. 

Though  exact  topography  of  anatomical  points  may  not  in  all  cases  he  secured,  it  is  thought 
that  by  careful  fixing  to  avoid  distortion,  care  in  the  dissection  and  preparation  of  the  specimens. 
equally  careful  manipulation  of  the  lighting  and  other  photographic  details,  all  of  which  was 
under  personal  supervision,  these  errors  are  reduced  to  the  minimum.  The  photograph  has  its 
limitations  compared  with  drawing,  in  that  it  is  impossible  to  change  the  picture  materially  and 
any  diagrammatic  representation  is  impossible;  but,  on  the  other  hand,  errors  in  drawing  are 
avoided,  and  by  the  crayon  retouching  the  picture  may  lie  strengthened  and  photographic 
defects  may  be  corrected. 

(1) 


The  collection  of  pathological  specimens  from  which  the  photographs  were  made  has 
extended  over  many  years,  and  are  selected  from  observations  in  2,350  autopsies.  Some  of  the 
specimens  are  quite  rare,  but  the  majority  are  representative  of  conditions  which  may  occur  at 
any  time  in  autopsies  among  the  insane.  An  endeavor  has  been  made  to  give  examples  of  most 
of  the  common  changes  found  in  the  adult  insane,  as,  on  account  of  the  few  children  among  our 
patients,  pathological  conditions  occurring  more  frequently  in  children  of  the  defective  class 
are  hard  to  secure  and  are  not  well  represented  in  the  collection. 

Following  the  classification  of  the  lesions  rather  than  the  mental  diseases,  the  plates  have 
been  arranged  with  this  regard  as  far  as  possible'.  This  is  not  always  easy  to  do,  and  certain 
morbid  conditions  will  be  found  to  merge  with  others.  In  most  instances  the  pathological 
condition  is  easily  recognized,  but  may  be  made  more  evident  by  comparison;  therefore,  lor  the 
purpose  of  contrast  I  have  occasionally  introduced  certain  more  normal  pictures  where  they 
may  best  serve  this  purpose. 

It  will,  of  course,  be  understood  that  the  lesions  represented  in  no  sense  are  to  be  considered 
as  showing  the  essential  morbid  anatomy  of  any  form  of  mental  disease,  except  general  paralysis 
and  possibly  senile  dementia  and  arteriosclerotic  dementia.  In  many  instances  the  lesions 
found  are  simply  accidental  and  may  occur  in  any  form  of  insanity  or  even  in  the  sane.  Senile 
and  arteriosclerotic  changes  may  supervene  in  any  form  of  chronic  insanity,  and  some  of  the 
changes  are  the  results  rather  than  the  essential  underlying  condition  or  causation.  There  are, 
however,  certain  conditions  which  are  naturally  associated  with  mental  failure,  such  as  extreme 
atrophy,  chronic  oedema,  advanced  arterial  disease,  and  the  results  of  former  hemorrhages; 
these  may  be  regarded  as  explanatory  of  mental  deterioration  in  general. 

The  mental  diseases  represented  are  many  of  them  given  under  the  older  classification,  and 
it  has  been  thought  best  not  to  change  these  diagnoses.  Almost  all  the  common  forms  of  men- 
tal affections  are  given  a  place;  certainly  all  which  may  show  gross  lesions  other  than  accidental. 
The  pathological  conditions  represented  are  arteriosclerosis,  cerebral  softenings,  hemorrha<_r<>. 
atrophies,  paresis  or  meningoencephalitis,  hydrocephalic  states,  meningeal  conditions,  cerebral 
compressions,  sclerotic  conditions,  and  intracranial  and  brain  tumors.  A  few  plates  represent 
comparatively  normal  brains  in  dementia  pnecox,  etc.,  introduced  for  comparison  and  contrast. 

Localization  of  the  special  senses,  an  extremely  interesting  but  difficult  matter  among  the 
insane,  has  only  incidentally  been  referred  to,  though  when  lesions  have  been  found  in  areas  of 
known  functions  the  clinical  histories  are  often  confirmatory.  Often,  however,  the  localization 
is  confused  by  a  multiplicity  of  lesions,  and  the  consequent  mental  deterioration  makes  the 
observations  extremely  unsatisfactory.  The  localization  of  motor  functions  in  the  cortex  and 
the  abolition  of  muscular  movements  in  lesions  of  the  internal  capsule  are  more  easily  deter- 
mined and  many  examples  occur. 

It  is  to  be  regretted  that  the  limitations  of  the  work  will  not  permit  of  more  extended 
reference  to  the  clinical  histories,  as  only  the  prominent  clinical  manifestations  and  the  form  of 
mental  disease  could  be  given.  The  preliminary  data  given  will  sometimes  be  found  to  bear 
an  important  relation  to  the  specimen,  which  will  be  readily  appreciated. 

An  apology  for  the  brevity  of  the  descriptions  is  perhaps  in  order,  though  in  most  instances 
the  plates  are  self-explanatory.  It  was  also  thought  best  not  to  disfigure  the  pictures  by  leaders 
or  other  indicators,  and  outlines  such  as  used  by  some  authors  were  impracticable.  To  those 
who  are  familiar  with  the  anatomy  of  the  brain  it  is  hoped  that  this  omission  may  not  be  vitally 
important. 


3 

To  the  authorities  to  whoso  generosity  I  owe  the  publication  of  the  work,  and  to  Dr.  William 
A.  White,  Superintendent,  whose  encouragement  and  support  made  its  preparation  possible,  I 
tender  my  sincere  thanks;  and  in  this  connection  I  would  not  forget  our  honored  former  super- 
intendents, to  whose  memory  I  am  ever  grateful  for  their  assistance  and  guidance  in  my  work. 
To  my  colleagues  and  all  who  have  aided  me  directly  or  indirectly  I  am  thankful,  and  to  William 
M.  Keeler,  the  hospital  photographer,  I  am  under  many  obligations  for  the  care  and  skill  which 
made  the  photographs  so  important  a  feature  of  the  work. 

Government  Hospital  fok  the  Insane, 

Washington,  D.  C,  June  10,  1908. 


I'LATK    I. 


(5) 


PLATE  I. 

Autopsy  No.  1(372. 

dissection  of  the  basal  arteries arteriosclerosis. 

Case  6604.  J.  N.;  male;  aged  58;  colored;  laborer;  nativity,  Georgia.  Mental  disease, 
epileptic  insanity;  duration,  over  eight  years. 

The  patient  had  chronic  disease  of  the  cardiac  valves,  slight  arteriosclerotic  interstitial 
nephritis,  and  sclerosis  and  distortion  of  the  cerebral  arteries,  with  a  small  softening  in  the  white 
matter  of  the  occipital  lobe. 

The  picture  shows  a  dissection  of  the  basal  arteries  made  by  removing  the  arachno-pia, 
leaving  the  vessels  in  situ.  Portions  of  all  the  vessels  are  shown,  and  the  arterial  disease,  as  well 
as  the  developmental  anomalies  present.  Both  posterior  communicating  arteries  are  enlarged, 
and  there  is  a  double  superior  cerebellar  on  the  right  side.  The  extreme  tortuosity  of  the 
anterior  inferior  cerebellar  artery  of  the  right  side  is  noteworthy. 

(6) 


GROSS   MORBID   ANATOMY  OF   THE   BRAIN    IN   THE   INSANE. 


^      i^k 


DISSECTION     OF    THE    BASAL    ARTERIES-ARTERIOSCLEROSIS. 


PLATE    II. 


(7) 
*7n7.s — 08 2 


PLATE   II. 

Autopsy  No.  1925. 

dissection  of  the  cerebral  artehies — arteriosclerosis. 

Case  1311.  T.  McD.;  male;  aged  S3;  white;  occupation  unknown;  nativity,  Pennsylvania. 
Mental  disease,  chronic  mania. 

The  arteries  of  the  brain  were  very  atheromatous,  distorted,  and  curved.  "Weight  of  brain, 
1,250  grains.  The  heart  was  hypertrophied,  and  the  valves  of  the  left  side  showed  some  chronic 
thickening.  The  kidneys  were  primarily  contracted,  but  the  left  contained  some  pus  deposits, 
a  condition  secondary  to  purulent  cystitis. 

The  picture  shows  a  dissection  of  the  cerebral  arteries  made  by  removing  portions  of  the 
brain  which  normally  obstruct  the  view.  Portions  of  all  of  the  principal  cerebral  arteries  are 
seen,  including  the  anterior  choroid  arteries,  that  of  the  right  side  being  visible  from  its  origin 
to  its  destination  in  the  choroid  plexus  of  the  descending  horn  of  the  right  lateral  ventricle. 
There  are  a  few  anomalies  of  minor  importance.  The  extreme  distortion  and  curvature  of  the 
arteries  consequent  upon  senile  arteriosclerosis  are  readily  seen. 

(8) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN  THE  INSANE. 


DISSECTION    OF    THE    BASAL    ARTERIES-ARTERIOSCLEROSIS. 


PLATE    III. 


0; 


PLATE   III. 

Autopsy  No.  1719. 

the  arteries  at  the  base  of  the  brain  in  advanced  calcareous  arteriosclerosis. 

Case  13662.  F.  F.  S. ;  aged  77;  white;  farmer;  nativity,  Pennsylvania.  Mental  disease, 
senile  dementia. 

Brain:  Weight,  1,200  grams.  Arteries  at  the  base  extremely  sclerotic,  distorted,  and  calci- 
fied. Great  atrophy  of  the  convolutions.  The  arteries  were  dissected  free  of  the  pia  arachnoid 
and  left  in  situ.  The  calcareous  patches  give  a  nodular  appearance  to  the  vessel  walls,  and  the 
extreme  distortion  of  the  principal  trunks  are  well  shown.  Parts  which  would  obstruct  the 
view  are  cut  away. 

The  heart  weighed  595  grains.  Slight  enlargement  of  the  tricuspid  orifice.  Some  chronic 
disease  of  the  left  valves.     Coronary  arteries  and  the  aorta  were  sclerotic. 

The  associated  conditions  of  other  organs  were  cystitis  and  pyelo-nephritis,  cholelithiasis, 
chronic  ulcerative  colitis,  and  two  large  hemorrhagic  infarctions  resulting  from  thrombosis  of 
the  splenic  artery,  which  was  very  atheromatous,   tortuous,   and  much  calcified. 

(10) 


GROSS   MORBID  ANATOMY  OF  THE   BRAIN   IN  THE   INSANE. 


ft.    %  J 


ri 


THE    ARTERIES    AT     THE     BASE    OF    THE     BRAIN     IN     ADVANCED    CALCAREOUS 

ARTERIOSCLEROSIS. 


PLATE    IV 


en) 


PLATE    IV. 
Autopsy  No.  171fla. 

A    DISSECTION    OF    SCLEROTIC    ARTERIES    OF    THE    MESIAL    SURFACE    AND    THE    INSULA,    ETC. 

Case  13662.  F.  F.  S.;  aged  77:  white;  farmer;  nativity,  Pennsylvania.  Mental  disease, 
senile  dementia. 

This  picture  shows  the  terminal  distribution  of  the  anterior  cerebral  artery  of  the  left  side 
after  removal  of  the  overlying  arachno-pia,  the  insular  and  temporal  branches  of  the  middle 
cerebral  artery  after  cutting  away  the  overlying  brain,  and  the  parts  within  the  right  lateral 
ventricle  after  removing  the  roof  and  the  right  side  of  the  callosum.  The  tortuous  condition 
and  the  patches  of  arteriosclerosis  of  the  smaller  arteries  are  particularly  well  shown  in  the 
vessels  of  the  insula. 

(12) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN  THE   INSANE. 


A    DISSECTION    OF    SCLEROTIC    ARTERIES    OF    THE     MESIAL    SURFACE    AND    THE 

INSULA,     ETC. 


PLATE    V. 


(13) 


PLATE  V. 

Autopsy  No.  1926. 

dissection  of  the  cerebral  arteries,  showing  an  anomalous  circle  of  willis. 

Case  13646.  A.  ('.:  male;  aged  78;  white;  soldier;  nativity,  Ohio.  Mental  disease,  senile 
dementia;  duration,  uncertain.     Partial  autopsy;  only  the  brain  examined. 

The  picture  shows  a  dissection  of  the  cerebral  arteries  at  the  base,  revealing  advanced 
arteriosclerosis  and  a  number  of  rare  developmental  anomalies  of  the  arteries,  the  most  note- 
worthy being  an  anastomotic  branch  of  large  size  arising  from  the  left  internal  carotid  and 
joining  the  basilar,  which  it  equals  in  size.  The  anterior  communicating  artery  is  double;  the 
right  anterior  inferior  cerebellar  artery  supplies  both  the  anterior  and  inferior  cerebellar 
branches;  the  left  anterior  inferior  cerebellar  artery  is  absent,  and  the  left  posterior  inferior 
cerebellar  artery  is  unusually  huge  and  furnishes  branches  which  take  the  place  of  the  absent 
anterior  cerebellar.     Other  deviations  from  the  normal,  of  minor  importance,  are  present. 

Note. — This  case  has  been  reported  in  detail  in  "Anomalies  of  the  encephalic  arteries 
among  the  insane,"  by  I.  W.  Blackburn,  M.  D.,  Journal  of  Comparative  Neurology  and 
Psychology,  November  6,  1907. 

(14) 


GROSS  MORBID  ANATOMY  OF  THE  BRAIN   IN   THE   INSANE. 


DISSECTION    OF    THE    CEREBRAL    ARTERIES,    SHOWING    AN     ANOMALOUS    CIRCLE 

OF    WILLIS. 


PLATE    VI. 


17078     08 X 


PLATE  VI. 

Autopsy  No.  2163. 

aneurisms  of  the  basal  arteries  and  an  anomalous  anterior  choroid  artery  of  the 

left  side. 

Case  15977.  A.  II.  S.;  aged  68;  male;  white;  nativity,  Kentucky.  Mental  disease,  senile 
dementia. 

Brain:  Weight,  1,320  grams.  Much  atrophied  and  the  leptomeninges  opaque.  The 
arteries  are  somewhat  sclerotic  and  are  distorted,  dilated,  and  curved.  The  left  anterior 
choroid  artery  is  large  and  lies  at  first  deep  in  the  hippocampal  fissure,  whence  it  emerges 
and  forms  the  parieto-occipital  and  the  calcarine  arteries.  The  posterior  cerebral  artery  is 
distributed  mainly  to  the  inferior  surface  of  the  temporal  lobe.  The  right  carotid  artery  at  its 
division  into  its  main  branches  is  dilated  into  an  aneurism;  a  slight  dilatation  of  the  left  exists 
at  the  same  situation.  At  the  junction  of  the  right  anterior  cerebral  with  the  anterior  com- 
municating artery  is  an  aneurism  about  one-fourth  of  an  inch  in  diameter. 

Other  pathological  findings  are  of  no  importance  in  this  connection. 

(16) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


ANEURISMS    OF    THE    BASAL    ARTERIES    AND    AN     ANOMALOUS    ANTERIOR    CHOROID 

ARTERY    OF    THE    LEFT    SIDE. 


PLATE    VII. 


>• 


PLATE  VII. 

Autopsy  No.  2094. 

the  base  of  the  brain,  showing  arteriosclerosis  and  anomalous  arteries. 

Case  28.54.  S.  S.  T.;  aged  68;  male;  white:  nativity.  Illinois.  Mental  disease,  chronic 
mania. 

The  picture  shows  the  basal  arteries  after  removal  of  the  arachnoid  and  some  dissection 
of  the  pia  to  show  the  smaller  vessels.  The  tortuosity  and  irregularity  of  the  sclerotic  arteries 
are  well  shown,  and  in  the  right  carotid  a  blood  clot  fills  the  lumen.  There  is  marked  curvature 
of  the  cerebellar  arteries,  and  the  vertebrals  and  the  basilar  are  curved,  the  convexity  of  the 
latter  being  toward  the  right.  The  anomalous  condition  of  the  arteries  consists  of  a  connecting 
artery  of  large  size  connecting  the  two  vertebrals  and  giving  origin  to  the  anterior  spinal  artery. 
Weight  of  brain,  1 ,390  grams. 

Other  pathological  conditions  bore  no  relation  to  the  condition  of  the  brain.  The  patient 
died  of  cystitis  and  pyelonephritis,  consequent  to  prostatic  enlargement. 

(18) 


GROSS   MORBID  ANATOMY  OF  THE   BRAIN   IN  THE  INSANE. 


THE     BASE    OF    THE     BRAIN,     SHOWING     ARTERIOSCLEROSIS    AND    ANOMALOUS    ARTERIES. 


PLATE    \  III. 


(19) 


PLATE  VIII. 
Autopsy   No.  2057. 

THE    BASE    OF    A    BRAIN'    SHOWING    ARTERIOSCLEROSIS. 

Case  8783.  A.  K.;  aged  77;  white;  late  soldier;  nativity,  Germany.  Mental  disease, 
chronic  melancholia. 

Brain:  Weight,  1,150  grams.  Arteries  at  the  base  dilated  and  sclerotic.  Both  posterior 
communicating  arteries  were  greatly  enlarged  and  furnished  the  blood  supply  to  the  posterior 
cerebral  regions,  as  the  posterior  cerebral  arteries  were  abnormally  small  at  their  origin  from 
the  basilar.  The  superior  cerebellar  arteries  were  rather  large,  the  anterior  inferior  cerebellar 
arteries  being  practically  absent  or  represented  by  very  small  branches.  The  posterior  inferior 
cerebellar  arteries  were  large,  extremely  tortuous,  and  took  the  place  of  the  anterior  inferior 
cerebellar  vessels  as  well.  The  right  vertebral  artery  was  disproportionately  small  and  the  left 
was  the  size  of  the  basilar.  The  latter  was  curved,  witli  its  convexity  toward  the  left.  The 
right  anterior  cerebral  artery  was  large  and  sent  the  main  blood  supply  to  the  opposite  territory 
through  a  large  anterior  communicating,  the  opposite  artery  being  small. 

The  condition  of  the  other  organs  is  unimportant  in  this  connection. 

(20) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


THE     BASE    OF     A     BRAIN     SHOWING    ARTERIOSCLEROSIS. 


PLATE    IX. 


(21) 


PLATE   IX. 
,  Autopsy  No.  2091. 
the  base  of  the  brain,  showing  arteriosclerosis  of  the  small  vessel  type. 

Case  9142.  A.  M.;  aged  81;  male;  white;  nativity,  Germany.  Mental  disease,  senile 
dementia. 

Brain:  Weight,  1,200  grams.  Much  shrinkage  of  brain  and  oedema  ex  vacuo  of  pia.  The 
arteries  show  only  slight  rigidity  and  opacity,  luit  are  greatly  curved.  This  is  especially  notice- 
able in  the  basilar  and  vertebral  arteries,  the  former  being  greatly  bent,  with  its  convexity 
toward  the  right.  In  both  internal  carotid  arteries  are  recent  dark  clots  completely  filling  the 
lumen.  These  are  not  true  ante-mortem  thrombi,  being  formed  either  shortly  before  or  after 
death. 

A  noticeable  feature  of  this  picture  is  the  extreme  relative  breadth  of  the  brain  compared 
with  its  antero-posterior  diameter — a  characteristic  of  many  German  brains. 

(22) 


GROSS  MORBID   ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


THE     BASE    OF    THE     BRAIN,     SHOWING     ARTERIOSCLEROSIS    OF     THE    SMALL     VESSEL    TYPE. 


PLATE    \. 


23 


17078-  08 i 


PLATE  X. 

Autopsy  No.  2042. 

the  base  of  a  brain  showing  arteriosclerosis. 

Case  7106.  A.  I.;  aged  63;  white;  nativity,  Germany.  Mental  disease  when  admitted, 
acute  mania;  now  arteriosclerotic  terminal  dementia. 

Synopsis  of  autopsy:  Brain  weight,  1,150  grams.  Convolutions  much  shrunken  over  the 
whole  brain.  Arteries  at  the  base  showed  advanced  arteriosclerosis  and  distortion.  The  left 
vertebral  artery  was  unusually  large,  passing  without  change  of  caliber  into  the  basilar;  the 
right  was  very  small,  almost  impervious,  and  the  posterior  inferior  cerebellar,  which  was  of  nor- 
mal size,  formed  the  main  continuation  of  the  cervical  portion  of  the  vertebral  vessel.  The 
anterior  spinal  artery  arose  from  the  left  vertebral,  and  the  left  anterior  inferior  cerebellar 
artery  came  off  the  basilar  much  above  its  usual  position.  The  basilar  was  strongly  curved, 
with  its  convexity  to  the  right;  the  superior  cerebellar  and  the  posterior  cerebral  arteries 
were  much  distorted. 

The  skull  cap  showed  some  nodular  exostoses  externally;  the  dura  was  adherent  and 
showed  a  faint  neo-membrane  over  the  inner  surface  of  the  convexity. 

The  lungs  contained  numerous  miliary  catarrhal  tubercles.  The  csecal  end  of  the  colon 
was  dislocated  and  the  small  bowel  occupied  the  right  iliac  fossa  in  its  stead. 

(2-1) 


GROSS  MORBID  ANATOMY  OF  THE  BRAIN   IN   THE   INSANE. 


THE     BASE    OF     A     BRAIN     SHOWING    ARTERIOSCLEROSIS. 


PLATE    XI. 


(25) 


PLATE  XI. 
Autopsy  No.  22(i'.i. 

DISSECTION    SHOWING    THE   DISTRIBUTION    OF   THE   ANTERIOR   CEREBRAL    ARTERIES    AND  THE 
DISTRIBUTION  OF  A  LARGE  MEDIAN  ANTERIOR   CEREBRAL  ARTERY. 

Case  11766.  A.  C;  aged  67;  male;  colored;  nativity,  Virginia.  Mental  disease,  senile 
dementia;  duration,  seven  years.     Death  from  exhaustion  and  pulmonary  hypostasis. 

Skull  thick  and  dense.     Dura  adherent  to  the  bone. 

Brain:  Weight,  1,240  grams.  Considerable  degree  of  shrinkage;  convolutions  much  cut 
up  by  secondary  fissures.  No  gross  lesions.  A  large  median  anterior  cerebral  artery  was  found 
arising  from  the  anterior  communicating  artery.  The  vessel  curved  around  the  genu  callosi  and 
continued  backward  along  the  corpus  callosum  to  a  point  opposite  the  paracentral  lobule,  where 
it  divided  into  four  equal  large  branches  which  supply  the  paracentral  and  quadrate  lobules  of 
the  two  sides.  The  two  true  anterior  cerebral  arteries  were  somewhat  smaller  than  the  abnor- 
mal vessel  and  were  distributed  to  the  anterior  portion  of  the  medial  surfaces.  The  picture 
shows  the  upper  part  of  the  anomalous  artery  left  in  situ,  while  the  left  hemisphere  is  partly  cut 
away.  The  arteries  distributed  to  the  left  hemisphere  are  partly  cut  away  and  in  part  left  free. 
The  left  insula  is  left  intact,  with  the  arteries  of  the  Sylvian  system  left  in  situ.  They  are  seen 
to  be  enlarged  and  tortuous,  showing  a  moderate  degree  of  senile  arteriosclerosis.  Some  slight 
disproportion  in  the  size  of  the  vertebrals  and  the  inferior  cerebellar  arteries.  A  small  cortical 
softening  on  right  orbital  surface. 

Lungs  hypostatic.  Heart  increased  in  weight;  the  valves  of  the  left  side  and  the  tricuspid 
are  incompetent.     Kidneys  a  little  contracted.     Other  organs  practically  normal. 

Note. — The  median  anterior  cerebral  artery — arteria  terrnatica  of  Wilder — is  found  in  a 
small  percentage  of  cases.  It  quite  commonly  divides  into  branches  which  supply  the  two 
adjoining  medial  surfaces  of  the  paracentral  and  quadrate  lobules.  It  is  not  uncommon  for  one 
of  the  true  anterior  cerebral  arteries  to  send  a  branch  to  the  opposite  hemisphere;  and  some- 
times only  one  anterior  cerebral  is  developed  into  a  large  callosal  trunk  with  branches  to  both 
surfaces,  while  the  opposite  vessel  is  only  distributed  to  the  anterior  part  of  its  own  hemisphere. 

(26) 


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PLATE  XII. 
Autopsy  No.  -'ill). 

A    LARGE    ARTERIOSCLEROTIC    SOFTENING    OF    THE    LEFT    HEMISPHERE. 

Case  717.'?.  W.  C;  aged  (j(i:  malo;  white;  former  soldier;  nativity,  Ireland.  Mental  dis- 
ease, chronic  dementia.     Patient  had  right  hemiplegia,  aphasia,  and  was  extremely  demented. 

Synopsis  of  autopsy:  The  brain  was  generally  atrophied.  Weight  of  right  hemiencephalon, 
22i  ounces  (637  grams);  the  left,  19  ounces  (538  grams).  On  the  left  side  a  large  softening. 
with  loss  of  substance,  had  involved  the  third  frontal  convolution,  the  insula,  lower  ends  of 
the  central  gvri,  inferior  parietal  lobule,  the  outer  surface  of  the  occipital  lobe,  and  the  greater 
part  of  the  superior  and  middle  temporal  convolutions.  The  arteries  were  sclerotic  and  calci- 
fied at  the  base,  and  a  thrombotic  obstruction  of  the  middle  cerebral  artery  of  the  left  side  had 
doubtless  caused  the  softening.  The  principal  branches  of  the  vessel,  in  the  fresh  condition 
containing  blood,  are  seen  lying,  apparently  well  preserved,  at  the  bottom  of  the  necrotic 
cavity.  The  fact  that  the  arteries  were  so  well  preserved  and  pervious  suggests  that  the 
cause  may  have  been  thrombosis  with  reestablishment  of  the  arterial  circulation. 

(28) 


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PLATE    XIII. 


(29) 


PLATE  XI11. 

Autopsy  No.   1">17. 

a  large  arteriosclerotic  .softening  ok  left  hemisphere. 

Case  10290.  S.  McF. ;  aged  83;  white;  male;  wheelwright;  nativity,  Kentucky.  Mental 
disease,  senile  dementia;  duration,  three  years.     Clinical  history  of  advanced  dementia. 

Synopsis  of  autopsy:  .Skull  unusually  thin;  sutures  obliterated;  dura  adherent  to  the  hone. 

Brain:  Weight  of  right  half,  600  grams;  left,  500  grams.  The  convolutions  were  generally 
atrophied;  organ  soft  and  (Edematous;  ventricles  dilated.  On  the  left  side  a  large  softening, 
with  loss  of  substance,  involved  the  greater  part  of  the  inferior  parietal  lobule,  the  first,  second, 
and  third  temporal  gyri,  and  the  outer  portion  of  the  occipital  lobe.  The  third  frontal  convo- 
lution, the  central  gyri,  and  the  anterior  portion  of  the  insula  had  escaped  injury.  The  obstructed 
arteries  may  still  be  seen  lying  at  the  bottom  of  the  cavity,  and  in  the  recent  condition  they 
contained  blood,  though  of  no  functional  value.  On  the  right  side  the  lower  portion  of  the 
cuneus  and  the  upper  part  of  the  lingual  and  fusiform  gyri  were  softened.  The  arteries  at  the 
base  wcii-  sclerotic  and  calcareous,  and  the  softenings  were  doubtless  secondary  to  the  vascular 

disease. 

(30) 


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PLATE    XIV. 


(31) 
47078—08 5 


PLATE  XIV. 
Autopsy  No.  1601. 
left  half  brain  with  multiple  cortical  softenings  due  to  arteriosclerosis. 

Case  9549.  D.  K.;  aged  72;  white;  late  soldier;  nativity,  Ireland.  Mental  disease,  senile 
dementia.     History  of  cardiac  asthma  and  general  muscular  enfeeblement  and  ataxic  aphasia. 

Synopsis  of  autopsy:  The  brain  weighed  1,100  grams.  On  the  left  hemisphere  there  were 
cortical  softenings,  with  contraction  and  puckering  of  adjoining  gyri,  affecting  the  third  frontal, 
middle  frontal,  upper  part  of  the  anterior  central  and  lower  part  of  the  posterior  central  con- 
volutions, a  large  area  in  the  superior  parietal  lobule,  and  the  outer  surface  of  the  occipital  lobe 
and  posterior  part  of  the  temporal  lobe.  Softenings  were  also  found  in  the  basal  ganglia  of 
this  side,  and  on  the  right  side  a  softening  involved  the  head  of  the  caudate  nucleus  and  the 
adjoining  anterior  limb  of  the  internal  capsule.  The  brain  showed  general  atrophy  and  cedema; 
arteries  sclerotic  and  calcified. 

The  patient  had  chronic  interstitial  myocarditis,  due  to  disease  of  the  coronary  arteries,  to 

which  was  attributed  the  asthmatic  attacks,  but  there  was  no  valvular  disease  which  could 

have  led  to  embolism;  therefore  the  softenings  were  believed  to  be  the  result  of  the  vascular 

disease. 

(32) 


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PLATE   XV. 


(33) 


PLATE  XV. 
Autopsy  No.  2089. 

the  base  of  the  brain,  showing  arteriosclerosis  of  the  basal  vessels  and  softening 
from  obstruction  of  the  right  posterior  cerebral  artery. 

Case  15546.  M.  J.;  aged  85;  female;  colored;  married;  nativity,  United  States.  Mental 
disease,  senile  dementia. 

Brain:  Weight,  1,030  grams.  The  picture  shows  marked  arteriosclerosis  of  the  basal 
arteries  and  a  large  softening  of  the  base  of  the  right  hemisphere,  involving  the  whole  of  the 
fusiform  lobule,  the  adjoining  convolutions,  and  the  extremity  of  the  occipital  lobe.  To  show 
the  extent  of  this  softening  and  to  show  the  disease  of  the  posterior  cerebral  artery  upon  which 
it  was  dependent,  the  right  hemisphere  of  the  cerebellum  has  been  cut  away.  There  is  a  decided 
disproportion  in  the  size  of  the  two  vertebral  arteries,  and  the  greatest  degree  of  arteriosclerosis 
is  noted  in  these  and  in  the  basilar  artery.  The  genu  of  the  callosum  was  softened,  and 
there  was  great  shrinkage  of  the  brain  over  the  convexity. 

The  kidneys  were  granular;  the  arteries  of  the  body  in  general  were  sclerotic.  The 
mucous  membrane  of  the  urinary  bladder  showed  chronic  catarrh. 

(34) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   XV. 


THE   BASE  OF  THE   BRAIN,  SHOWING  ARTERIOSCLEROSIS  OF  THE   BASAL  VESSELS  AND 
SOFTENING    FROM   OBSTRUCTION   OF  THE   RIGHT   POSTERIOR  CEREBRAL  ARTERY. 


PLATE    XVI. 


(35) 


PLATE  XVI. 

Autopsy  No.  2063. 

a  horizontal  section  of  a  brain  showing  central  softenings  from  arteriosclerosis. 

Case  15068.  J.  B.  C. ;  aged  66;  white;  farmer;  nativity,  Ohio.  Mental  disease,  organic 
dementia;  senile  arteriosclerosis. 

Synopsis  of  autopsy:  Senile  gangrene  of  three  toes  of  left  foot. 

Brain:  Weight,  1,290  grams.  Organ  moderately  shrunken  over  the  whole  convexity. 
Arteries  sclerotic  and  calcareous.  Section  showed  the  tissue  oedematous  and  soft;  ventricles 
dilated;  on  the  right  side  a  large  softening  extended  from  the  anterior  portion  of  the  insular 
gyri  through  to  the  ventricle,  involving  in  its  course  nearly  the  whole  of  the  lenticular  nucleus, 
the  capsules,  and  the  head  of  the  caudate.  The  posterior  limb  of  the  internal  capsule  and  the 
thalamus  were  involved,  but  to  a  less  degree,  the  posterior  two-thirds  of  the  former  being  fairly 
preserved.  On  the  left  side  the  ganglia  and  capsules  were  intact.  The  left  vertebral  artery 
was  very  small,  the  right  unusually  large,  anil  entered  without  change  of  caliber  into  the  basilar. 
The  right  anterior  cerebral  artery  was  small  at  its  origin,  and  the  left  was  correspondingly 
large,  furnishing  the  main  blood  supply  to  the  opposite  region  through  an  enlarged  anterior 
communicating  artery. 

The  other  organs  showed  nothing  of  importance  except  a  generalized  arteriosclerosis. 

(36) 


GROSS   MORBID   ANATOMY   OF   THE    BRAIN    IN   THE   INSANE. 


-.•^ 


A    HORIZONTAL    SECTION     OF    A    BRAIN    SHOWING    CENTRAL    SOFTENINGS 
FROM    ARTERIOSCLEROSIS. 


PLATE    XVII. 


(37) 


PLATE  XVII. 

Autopsy  No.  2104. 

a  horizontal  section  of  brain  showing  central  arteriosclerotic  softenings. 

Case  14246.  A.  S. ;  aged  63;  male;  white;  soldier;  nativity,  United  States.  Mental 
disease,  organic  dementia. 

Brain:  Weight,  1,210  grams.  Arteriosclerosis;  brain  shrunken  and  oedematous.  A  large 
chronic  softening,  revealed  by  horizontal  section,  was  found  to  involve  the  insular  cortex,  white 
.substance  of  the  insula,  the  claustrum,  external  capsule,  lenticular  nucleus,  the  internal  capsule, 
the  outer  portion  of  the  head  of  the  caudate  nucleus,  and  almost  the  whole  thalamus.  The 
ventricles  were  considerably  dilated. 

Other  pathological  conditions  were  cardiac  aneurism  from  interstitial  myocarditis,  chronic 
disease  of  the  aortic  and  mitral  valves,  hypertrophy  and  dilatation  of  heart,  and  relative  incom- 
petency of  tricuspid  valve.     Other  pathological  findings  of  no  importance  in  this  connection. 

The  patient  had  long  suffered  from  left  hemiplegia,  attributed  to  cerebral  hemorrhage,  but 

there  were  no  evidences  of  former  hemorrhage,   the   lesion  being  destructive   arteriosclerotic 

softenings. 

(38) 


GROSS   MORBID   ANATOMY   OF   THE   BRAIN    IN    THE    INSANE. 


PLATE  XVII. 


A    HORIZONTAL    SECTION    OF     BRAIN    SHOWING    CENTRAL    ARTERIOSCLEROTIC 

SOFTENINGS. 


PLATE    XVIII. 


39 

17117s— |>S G 


PLATE  XVIII. 

Autopsy  No.  1961. 

a  horizontal  section  of  a  brain  showing  syphilitic  softenings  of  the  interior  and 

CORTEX. 

Case  14124.  J.  S.;  aged  30;  white;  soldier;  nativity,  United  States.  Mental  disease, 
syphilitic  dementia  with  right  hemiplegia  and  aphasia. 

Synopsis  of  autopsy:  Brain  weight,  1,730  grams.  The  organ  showed  softenings  involving 
the  posterior  portion  of  the  left  frontal  lobe,  lower  ends  of  the  central  gyri,  lower  part  of  the 
inferior  parietal  lobule,  and  the  whole  of  the  insula  and  the  overlying  opercula.  On  the  right 
side  a  similar  softening  affected  the  lower  part  of  the  inferior  parietal  lobule  and  part  of  the 
supramarginal  gyrus.  On  section,  the  softenings  of  the  left  side  were  found  to  involve  the 
insula,  external  capsule,  lenticular  nucleus,  a  part  of  the  anterior  limb,  and  a  portion  of  the 
posterior  part  of  the  posterior  limb  of  the  internal  capsule.  On  the  right  side  the  head  of  the 
caudate  and  the  whole  of  the  lenticular  nucleus  and  the  anterior  limb  of  the  internal  capsule 
were  destroyed.     The  arteries  at  the  base  showed  syphilitic  arteriosclerosis. 

Multiple  gummata  of  the  liver  and  depressed  and  pigmented  dermal  scars  were  further 
evidences  of  the  nature  of  the  softenings. 

(40) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


A    HORIZONTAL    SECTION    OF    A    BRAIN    SHOWING    SYPHILITIC    SOFTENINGS 
OF    THE    INTERIOR    AND    CORTEX. 


PLATE    XIX. 


ii 


PLATE  XIX. 

Autopsy  No.  2080. 

a  horizontal  section-  of  a  brain  showing  (tkatric  ial  central  softenings. 

Case  L5070.  R.  K. :  aged  68;  white:  soldier;  nativity,  Ohio.  Menial  disease,  post- 
paralytic dementia;  aphasia. 

Brain:  Weight,  1,400  grams.  Arteries  at  the  base  very  atheromatous;  right  posterior 
communicating  artery  large;  both  anterior  cerebellar  arteries  very  small.  Brain  generally 
atrophied.  Cortical  softening  in  the  anterior  extremity  of  the  left  temporal  lobe  and  in  the 
posterior  portion  of  the  insular  face  of  the  same  lobe.  Section  showed  dilatation  of  the  ventricles. 
On  the  left  side  a  softening  was  found,  involving  the  lenticular  nucleus,  the  genual  portion  of 
the  internal  capsule,  and  the  head  of  the  caudate.  On  the  right  side  almost  the  same  condition 
existed,  with  possibly  a  little  less  involvement  of  the  facial  bundle  of  the  capsule  and  more 
destruction  of  the  head  of  the  nucleus  caudatus. 

A  strangulation  of  the  colon  was  found,  caused  by  t lie  small  bowel  and  its  mesenterv 
passing  over  and  above  the  hepatic  flexure  of  the  colon.  This  portion  of  the  colon  had  been 
dislocated  and  was  held  to  the  anterior  parieties  of  the  abdomen  by  a  fibrous  band.  The  bulk 
of  the  small  intestine  lay  in  the  right  iliac  fossa;  its  vessels  were  deeply  engorged. 

(42) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN  THE   INSANE. 


A    HORIZONTAL    SECTION     OF    A    BRAIN    SHOWING    CICATRICIAL    CENTRAL 

SOFTENINGS. 


PLATE    XX. 


13 


(PLATE  XX.) 

Autopsy  No.  1909. 

the  superior  aspect  of  the  brain  in  a  case  of  thrombotic  softening  affecting  tiik 

whole  left  hemisphere. 

Case  9060.  O.  B.;  aged  6!);  white;  female;  nativity,  United  .States.  Mental  disease,  chronic 
melancholia.  Clinical  history  showed  that  she  had  a  general  convulsion,  followed  by  right  hemi- 
plegia, six  days  before  her  death.  She  did  not  recover  complete  consciousness,  and  another 
convulsion  occurred  the  next  day.  After  this  she  remained  semicomatose,  gradually  deepen- 
ing into  complete  coma  two  days  before  death  occurred. 

Brain  weight ,  1,200  grams.  Arteries  at  the  base  markedly  sclerotic  and  tortuous.  Both 
posterior  communicating  arteries  large,  and  the  left  furnished  the  main  blood  supply  to  the 
posterior  cerebral  area,  as  the  posterior  cerebral  artery  was  practically  obliterated  by  disease  at 
its  origin  from  the  basilar.  A  clot  had  formed  in  the  upper  end  of  the  left  carotid,  cutting  oil' 
the  supply  from  all  the  vessels  arising  from  this  carotid,  and  the  anterior  communicating  artery 
was  obliterated  by  disease.  The  left  hemisphere  was  thus  deprived  of  blood  and  had  undergone 
acute  softening.  The  hemisphere  was  swollen,  dark  red,  soft,  and  the  veins  were  deeply 
engorged.  The  right  hemisphere  showed  some  atrophy  and  some  venous  engorgement.  The 
pia  over  the  convexity  was  thick  and  opaque. 

i  44i 


GROSS  MORBID  A 


NATOMY  OF  THE   BRAIN   IN   THE  INSANE. 


PLATE   XX. 


THE    SUPERIO 
SOFTE 


ir     ASPECT    OF    THE    BRAIN     IN     A    CASE    OF    THROMBOTIC 
mNG    aIfEC?ING    THE    WHOLE    LEFT     HEMISPHERE. 


PLATE    XXI. 


PLATE   XXI. 

Autopsy  No.  -'150. 

arteriosclerotic  softenings  of  cerebrum  and  cerebellum. 

Case  S'.il'S.  J.S.;  aged  63;  female;  white;  nativity,  United  States.  Mental  disease,  acute 
mania  on  admission;  duration,  thirteen  years.  The  patient  became  markedly  demented.  She 
had  a  sensation  of  falling  and  would  scream  for  help.  She  had  marked  contraction  of  the 
extremities;  some  paralysis  of  the  left  side.  Large  abdominal  tumor  of  the  left  side  of  the 
abdomen,  found  at  the  autopsy  to  be  an  enlarged  spleen.  The  patient  had  been  blind  for 
some  time. 

Brain:  "Weight,  1,050  grams.  Great  general  atrophy  of  the.  brain,  with  mdema  ex  vacuo 
of  the  pia  mater.  Veins  were  prominent  and  overfilled;  some  were  partially  obstructed  by 
thrombi.  The  arteries  at  the  base  were  sclerotic  and  the  following  obstructions  existed:  Both 
posterior  cerebral  arteries  were  obstructed  as  they  curved  around  the  crura,  and  as  a  result 
softenings  were  found  at  the  distribution  of  all  of  their  principal  branches.  On  the  right  side 
the  lingual  and  fusiform  lobules  were  extremely  softened.  This  area  included  the  subcalca- 
rine  gyrus  and  the  whole  euneus,  and  extended  through  to  the  posterior  horn.  On  the  left 
side  the  lingual  gyrus  and  the  euneus  were  greatly  softened,  but  the  latter  was  still  dis- 
tinguishable. A  large  softening  was  found  on  the  outer  surface  of  the  left  occipital  lobe.  Sec- 
tion of  the  cerebrum  showed  no  softenings  of  the  basal  nuclei  nor  capsules.  The  softenings 
noted  above  were  found  to  extend  through  to  the  lining  of  the  ventricles,  and  the  softenings  of 
the  left  euneus  were  more  extensive  than  noted  on  the  surface.  The  left  hemisphere  of  the  cere- 
bellum showed  a  large  softening  of  the  posterior  border  and  another  on  its  under  surface,  both  of 
which  extended  deeply  into  the  white  matter.  The  right  hemisphere  showed  a  somewhat 
acute  softening  of  the  posterior  border.  These  softenings  were  due  to  obstructions  of  the  left 
posterior  inferior  cerebellar  artery;  on  the  right  side  there  was  some  obstruction  of  the  branches 
of  the  right  posterior  inferior  cerebellar  artery. 

The  right  lung  showed  some  oJd  tuberculous  deposits  and  a  recent  eruption  of  miliary 
tubercles;  a  small  gangrenous  cavity  in  right  lower  lobe. 

Heart  showed  some  sclerosis  of  its  arteries;  some  fibrosis  of  papillary  muscles. 

Spleen:   Organ  greatly  enlarged;  weight,  690  grams. 

Kidneys:  Some  interstitial  changes;  pelvis  of  left  contained  two  large  calculi. 

Liver:  Weight,  90  grams.  Nutmeg  appearance  of  tissue:  small  mass  of  encysted  calculi  in 
gall  bladder. 

Appendix  vermiformis  situated  behind  the  caecum. 

Two  small  leioinyomata  in  the  uterus. 

(46) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE  INSANE. 


PLATE   XXI. 


ARTERIOSCLEROTIC    SOFTENINGS    OF    CEREBRUM. 


PLATE    XXII. 


(47) 
17078—08 7 


PLATE  XXII. 
Autopsy   No.  2054. 
a  brain  the  seat  of  a  large  hemorrhage,  causing  left  hemiplegia. 

Case  130S5.  J.  K.;  aged  69;  white;  soldier;  nativity,  New  York.  Mental  disease,  chronic 
melancholia.     An  attack  of  apoplexy,  with  complete  left  hemiplegia,  five  days  before  death. 

Brain:  Weight,  1,400  grams.  Vessels  sclerotic;  left  vertebral  artery  represented  by  a  mere 
threadlike  vessel.  Incision  showed  a  large  hemorrhage  on  the  right  side,  between  the  insula 
and  the  basal  ganglia.  A  remnant  of  the  lenticular  nucleus  is  still  distinguishable  and  the 
greater  part  of  the  internal  capsule  is  still  seen.  The  hemorrhage  had  torn  across  the  capsule  at 
the  posterior  and  anterior  extremities;  how  much  greater  the  destruction  was  at  other  levels 
could  not  be  shown  in  the  picture.  The  right  side  is  seen  to  be  intact.  The  displacement  of  the 
basal  ganglia,  an  enlarged  pseudocele,  and  several  small  foci  of  softening  in  the  white  substance 
are  clearly  shown,  and  to  some  extent  the  flattening  out  of  the  sulci  and  gyri  of  the  right  side 
by  the  pressure  of  the  clot. 

Nothing  of  importance  was  found  in  the  other  organs,  except  cardiac  valvular  disease  and 
hypertrophy  and  a  large  Meckel's  diverticulum. 

(48) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE  INSANE. 


PLATE   XXII. 


A     BRAI 


N     THE    SEAT    OF    A    LARGE    HEMORRHAGE,    CAUSING    LEFT     HEMIPLEGIA. 


PLATE    XXIII. 


19 


PLATE  XXIII. 

Autopsy  No.  2037. 

a  horizontal  section  of  a  brain  showing  hemorrhage  in  the  right  basal  ganglia. 

Case  1348S.  M.  G.;  aged  74;  white;  soldier;  nativity,  Switzerland.  Mental  disease, 
chronic  melancholia  with  senility  and  dementia.  Cerehral  hemorrhage  twenty-four  hours 
before  death. 

Brain:  Weight,  1,350  grams.  Organ  much  shrunken  over  the  anterior  portion  of  the  frontal 
lobes.  Incision  showed  a  hemorrhage  on  the  right  side,  between  the  posterior  portion  of  the 
external  capsule  and  the  lenticular  nucleus,  separating  the  two  structures  about  1J  centimeters. 
Rupture  had  taken  place  through  the  lenticular  nucleus  into  the  middle  of  the  posterior  limb  of 
the  internal  capsule,  and  a  few  small  foci  of  hemorrhage  were  found  in  the  lenticular  nucleus 
around  the  vessels.  Large  perivascular  spaces  in  the  basal  ganglia  and  capsules.  The  ventricles 
were  moderately  enlarged.     The  arteries  were  sclerotic. 

The  skull  was  quite  irregular  on  the  outer  surface,  and  the  diploe  was  deeply  congested  and 
the  tables  thin  over  the  posterior  frontal  and  parietal  regions.  In  these  places  the  bone  was 
easily  penetrated  with  the  knife.  The  heart  weighed  400  grams;  left  auriculo-ventricular  ring 
calcified;  left  valves  thickened;  aorta  atheromatous.  Kidneys  slightly  contracted.  Other 
organs  presente< I  nothing  important. 

(50) 


GROSS   MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE  XXIII. 


A    HORIZONTAL    SECTION    OF    A    BRAIN    SHOWING    HEMORRHAGE    IN    THE    RIGHT    BASAL 

GANGLIA. 


PLATE    XXIV. 


(51) 


PLATE  XXIV. 

Autopsy  No.  121 14. 

cerebral    hemorrhage    destroying    the    right    internal    capsule    and    the    nucleus 

lentiformis. 

Case  5920.  ('.  A.  J.;  aged  56;  male;  white;  soldier:  nativity,  Germany.  Mental  disease, 
chronic  mania.  The  patient  had  a  cerebral  hemorrhage  two  days  before  death.  Paralysis  of 
left  side;  able  to  talk  until  coma  supervened. 

Brain :  Weight,  1 ,510  grams.  Extensive  subpial  effusion  of  blood  over  right  side, pons, inter- 
peduncular space,  and  superior  surface  of  cerebellum.  Convolutions  of  right  side  flattened 
against  the  dura.  Section  showed  a  large  hemorrhage  on  the  right  side,  which  had  completely 
destroyed  the  nucleus  Ientiformis,  posterior  limb  of  internal  capsule,  external  capsule,  claustrum, 
and  had  torn  through  the  insular  cortex,  escaping  into  the  Sylvian  fissure.  It  bad  not  pene- 
trated into  the  ventricular  cavity.  On  the  left  side  a  small  softening  was  found  in  the  nucleus 
Ientiformis  and  some  small  perivascular  softenings.  The  arteries  were  sclerotic  and  tortuous, 
and  some  minor  anomalies  were  found. 

The  other  organs  were  not  all  normal,  but  presented  no  important  conditions. 

(52) 


GROSS  MORBID   ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   XXIV. 


CEREBRAL    HEMORRHAGE    DESTROYING    THE    RIGHT    INTERNAL    CAPSULE    AND 
THE    NUCLEUS    LENTIFORMIS. 


PLATE   XXV. 


1,53; 


PLATE  XXV. 

Autopsy   No.    14S(i. 

HORIZONTAL    SECTION    OF    A    BRAIN    WHICH    HAD    BEEN    THE    SEAT    OE    A    HEMORRHAGE. 

Case  1072(5.  E.  A.  J.;  a^ed  77;  white;  female;  nativity,  Virginia.  Mental  disease, 
organic  dementia.  Clinical  history  of  a  hemorrhage  ten  years  before  death,  causing  aphasia 
and  hemiplegia,  both  of  which  symptoms  improved. 

Brain:  Not  weighed.  The  organ  presented  the  general  appearance  of  a  senile  brain. 
Arteries  at  the  base  sclerotic;  convolutions  generally  shrunken;  no  gross  lesions  of  the  cortex. 

The  picture  shows  the  lesion  situated  on  the  leftside,  involving  in  softening  and  loss  of  sub- 
stance the  lenticularis,  the  claustrum,  external  capsule,  and  the  white  matter  of  the  insula. 
The  posterior  two-thirds  of  the  posterior  limb  of  the  internal  capsule  seem  to  be  intact;  a  soften- 
ing crosses  the  tract  just  behind  the  genual  bundle  and  affects  the  thalamus,  and  the  anterior 
limb  is  slightly  encroached  upon.  The  intact  condition  of  those  structures  on  the  right  side 
furnishes  a  good  standard  for  comparison. 

(54) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE  INSANE. 


PLATE   XXV. 


HORIZONTAL  SECTION   OF  A   BRA,N   WHICH    HAD   BEEN   THE  SEAT   OF  A   HEMORRHAGE. 


PLATE    XXVI. 


55 

)7i  17s     us s 


PLATE  XXVI. 

Autopsy  No.   1969. 

horizontal  section  of  a  brain  showing  the  effects  of  former  hemorrhage. 

Case  11960.  B.  W. ;  aged  60;  male;  white;  soldier;  nativity,  Kentucky.  Mental  disease, 
chronic  epileptic  dementia.  Clinical  history  of  right-sided  hemiplegia,  with  aphasia,  about  three 
years  before  death.  The  patient  gradually  regained  the  use  of  the  right  arm  and,  to  a  less  degree, 
that  of  the  right  leg,  and  his  speech  distinctly  improved.  Finally  he  had  a  renewed  attack  of 
paralysis,  but  no  additional  speech  disturbance;  in  this  attack  death  occurred. 

The  picture  shows  a  narrow  line  of  loss  of  substance  and  a  small  cavity  to  the  outer  side  of 

the  left  lenticular  nucleus.     Careful  examination  will  show  that  this  loss  of  tissue  includes  the 

external  capsule  and  the  claustrum.     In  the  fresh  condition  this  lesion  had  a  yellow-ocher  color, 

indicative  of  former  hemorrhage,  and  the  structures  absent  were  probably  destroyed  at  the  time 

or  by  secondary  softening.     The  lenticularis  and  internal  capsule  are  intact,  except  two  bands 

of  acute  softening  which  cross  the  hitter  and  were  probably  the  lesions  causing  the  recent  attack. 

On  the  right  side  a  small  hemorrhagic  softening  is  seen,  affecting  the  lenticular  nucleus  and  the 

adjoining  external  capsule. 

J  8  (56) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN    IN   THE   INSANE. 


PLATE   XXVI. 


HORIZO 


NTAL    SECTION    OF    A    BRAIN    SHOWING    THE    EFFECTS    OF    FORMER 
HEMORRHAGE. 


PLATE    XXVII. 


(57) 


PLAT E XXVII. 
Autopsy  No.   \A22. 

THE    LEFT    HEMISPHERE    IN    A    CASE    OF    EXTREME    CEREBRAL    ATROPHY. 

Case  8719.  J.  II.:  aged  54;  white;  soldier:  nativity.  Massachusetts.  Mental  disease, 
chronic  dementia:  duration,  nine  years.  The  patient  had  been  operated  upon  for  some  sup- 
posed localized  brain  disease.  The  predominating  symptoms  were  extreme  dementia,  but  with- 
out  definite   paralysis:  loss  of  hearing;   memory   poor. 

Synopsis  of  autopsy:  Skull  thick  and  dense;  deficiency  of  bone  on  the  left  side  at  the  infe- 
rior posterior  angle  of  the  left  parietal  bone,  about  If  by  1  inch  in  diameters  and  roughly  oval 
in  shape.  Dura  generally  thick  and  adherent  to  bone,  and  at  the  site  of  the  bone  lesion  dura. 
pia,  and  cortex   were  adherent   together. 

Brain:  Weight,  1,091  grams.  The  left  hemiencephalon  weighed  about  15  grams  less  than 
the  right.  Extreme  atrophy  of  the  frontal  region  and  the  anterior  temporal  poles:  the  central 
regions  better  preserved  on  both  sides.  On  the  right  side  the  anterior  portion  of  the  temporal 
lobe  was  softened,  and  on  the  left  the  posterior  portion  of  the  temporal  lobe  and  the  adjoining 
part  of  the  inferior  parietal  lobule  was  softened,  corresponding  with  the  lesion  of  the  skull  above 
mentioned.  There  were  no  central  softenings.  The  arteries  were  sclerotic  and  distorted, 
though  not   i>>  a  great  degree. 

(58) 


X 

UI 

h 
< 


S 

o 

h 
< 


PLATE   XXVIII. 


(59) 


PLATE  XXVIII. 

Autopsy  No.  572. 

the  superior  surface  of  a  brain  from  a  case  of  senile  dementia  with  numerous  cortical 

softenings,  due  to  arteriosclerosis. 

Case  7100.  J.  II.;  aged  82;  white;  soldier;  nativity,  Switzerland.  Mental  disease,  senile 
dementia.      Right  brachial  monoplegia,  and  incoordination   of  muscular  movements. 

Brain:  Weight,  970  grams.  Extreme  general  atrophy  of  the  whole  brain.  Pia  opaque; 
cerebral  veins  tortuous  ami  engorged;  the  arteries  sclerotic  and  calcareous.  The  posterior 
communicating  arteries  were  only  connected  to  the  posterior  cerebral  vessels  by  impervious 
threadlike  cords.  All  the  parts  at  the  base  were  markedly  atrophied.  On  removal  of  the  pia 
after  hardening  in  Midler's  fluid,  a  number  of  small  cortical  softenings,  with  puckering  of  the 
surface,  were  found  over  various  parts  of  the  brain,  and  the  atrophy  and  widening  of  the  sulci 
are  well  shown.     A  softening  of  the  arm  center  in  the  left  precentral  gyrus  is  noteworthy. 

The  heart  showed  advanced  calcareous  disease  of  the  left  valves.  Kidneys  were  con- 
tracted— arteriosclerotic  interstitial  nephritis.  Liver  weighed  000  grams.  It  was  atrophied 
and   there  was  some  cirrhosis. 

Other  organs  showed   nothing  of  importance. 

Note. — I  think  the  shape  and  size  of  the  brain  are  better  preserved  by  hardening  in  Midler's 
fluid  than  in   formalin,  and   the  color  does  not   interfere  much  with  photography. 

(601 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   XXVIII. 


tup     cmpfriaR    SURFACE    OF    A    BRAIN     FROM    A    CASE    OF    SENILE    DEMENTIA    WITH 
THE    SU     NUMEROUS    CORTICAL    SOFTENINGS,    DUE    TO    ARTERIOSCLEROSIS. 


PLATE    XXIX. 


(61) 


PLATE  XXIX. 

Autopsy  No.  *.i7l'. 

extreme  atrophy  of  frontal  regions  of  the  brain. 

Case  8397.  J.  Y. ;  aged  (i.5;  male;  white;  soldier;  nativity,  Pennsylvania.  .Mental  dis- 
ease, chronic  dementia;  duration,  three  years. 

Skull  a  little  thicker  than  usual  in  the  frontal  regions.     Dura  adherent  to  bone. 

Brain:  Weight  of  left  hemiencephalon,  553  grams;  right,  503  grams.  Pia  mater  cedema- 
tous,  faintly  opaque  over  convexity.  Arteries  at  the  base  sclerotic;  smaller  branches  not 
diseased.  On  the  left  side  there  was  marked  atrophy  of  the  frontal  lobe  anterior  to  the  precentral 
gyrus,  except  a  small  part  of  the  base  of  the  middle  frontal  gyrus.  On  the  right  side  the  whole 
frontal  lobe  in  front  of  the  precentral  gyrus, the  anterior  part  of  the  paracentral  lobule, and  pos- 
terior portion  of  the  gyrus  cinguli  were  greatly  atrophied.  Other  areas  of  atrophy  were  found 
in  the  right  gyrus  angularis,  the  middle  and  inferior  temporal  gyri,  and  the  anterior  pole  of  the 
temporal  lobe.  Removal  of  the  pia  from  the  atrophied  regions  showed  that  the  brain  tissue 
was  soft,  brownish  in  color,  and  the  fissures  were  collapsed  and  the  gyri  flattened.  Incision 
into  the  basal  ganglia  showed  numerous  softenings  of  small  size,  but  no  destruction  of  the  cap- 
sules on  either  side.  The  ventricles  were  greatly  dilated ;  parts  in  the  interior  very  soft.  The 
preservation  of  the  motor  areas  and  the  capsules  accounts  for  the  absence  of  paralysis,  while 
there  was  almost  complete  dementia. 

(62) 


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PLATE   XXX  . 

Autopsy  No.  1805. 

the  superior  surface  of  the  cerebrum,  showing  atrophy;  the  fissures  are  artificially 

separated. 

Case  14180.  E.  J.  II.;  aged  77;  male;  white;  nativity,  United  States.  Mental  disease, 
senile   dementia. 

The  brain  weighed  1,220  grams.  Pia  very  (Edematous;  convolutions  greatly  shrunken. 
Arteries  at  the  base  sclerotic  and  calcareous.  The  lung  showed  hypostatic  pneumonia,  and  a 
small  abscess  cavity  in  the  right.  Chronic  disease  of  the  aortic  and  mitral  valves.  Chronic 
contraction  of  the  kidneys,  with  recent  pus  deposits.  Bladder  hypertrophied  and  slightly 
catarrhal.     Prostate  gland  enlarged. 

The  photograph  was  made  after  the  principal  fissures  had  been  carefully  separated  and 
kept  so  by  packing  lightly  with  absorbent  cotton  until  the  brain  hardened,  the  design  being  to 
make  an  anatomico-pathological  specimen.  The  two  hemispheres  are  separated,  showing  the 
callosum  and  cerebellum  in   the   depth  of  the  median  fissure. 

(64) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE  XXX. 


THE    SUPERS    SURFACE    OF JHE^EREB^UM,    8HOW.NG    ATROPHY;    THE    F.SSURES 


PLATE    XXXI. 


(65) 


PLATE  XXXI. 

Autopsy  No.   1921. 

the  superior  surface  of  a  brain  of  chronic  dementia  with  cerebral  atrophy. 

Case  11540.  O.K.;  aged  68;  white;  soldier;  nativity,  Germany-  Mental  disease,  chronic 
dementia. 

Brain:  Weight,  1,000  grams.  Pia  mater  slightly  opaque;  arteries  a  little  dilated,  but 
otherwise  normal;  convolutions  greatly  shrunken  over  the  whole  convexity.  Brain  pale  and 
(edematous. 

The  heart  showed  some  patches  of  epicardial  thickening.  Valves  of  left  side  thickened 
and  calcareous.  Kidneys  showed  same  areas  of  interstitial  change.  Stomach  slightly  dilated; 
walls  thin. 

The  cause  of  the  atrophy  of  the  brain  was  not  clearly  explained  by  either  the  general 
condition  or  the  state  of  the  vessels. 

The  picture  shows  the  shape  of  the  encephalon  quite  well  preserved,  the  head  being  the 
brachycephalic  type  frequently  met  with  in  Germans.  It  may  he  contrasted  with  brains  like 
No.  1940,  Plate  XL,  and  compared  with  No.  572,  Plate  XXVIII. 

Note. — The  patient  had  sustained  a  fracture  of  the  right  radius,  and  later,  one  of  the  neck 
of  the  right  femur.  He  became  very  feeble  and  markedly  emaciated,  and  had  toward  the  end 
of  life  some  cystitis. 

(66) 


GROSS   MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE    XXXI. 


THE    SUPERIOR    SURFACE    OF    A    BRAIN     OF    CHRONIC    DEMENTIA    WITH    CEREBRAL 

ATROPHY. 


PLATE    XXXII. 


(67) 


PLATE  XXXII. 

Autopsy  No.   1861. 

the  superior  aspect  of  the  brain  in  a  case  of  chronic  dementia  with  atrophy. 

Case  14235.  G.  B.;  aged  79;  white;  soldier;  nativity,  Germany.  Mental  disease,  chronic 
dementia.     Clinical  history  of  advanced  dementia;   general  enfeehlement ;    facial  erysipelas. 

Brain:  Weight,  1 ,180  grams.  The  organ  showed  marked  atrophy,  especially  of  the  anterior 
portions  of  the  frontal  lobes.  The  arteries  were  atheromatous  in  patches,  but  not  markedly 
sclerotic  for  a  man  of  the  patient's  age.  The  pia  was  easily  removed,  filled  with  serum,  and  the 
veins  were  moderately  full  of  blood.  The  picture  shows  some  widening  of  the  sulci  over  the 
whole  surface,  but  the  shrinkage  of  the  convolutions  is  most  noticeable  in  the  frontal  regions. 
The  brachycephalic  type  of  brain  characteristic  of  the  race  may  be  recognized  in  the  picture. 

The  heart  was  moderately  enlarged ;  slight  thickening  of  left  valves.  Aorta  atheromatous, 
especially  at  the  lower  end. 

Kidneys  showed  some  interstitial  change.  The  liver  was  slightly  granular  on  the  surface, 
and  the  gall  bladder  contained  numerous  small  calculi. 

(08) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   XXXII. 


THE    SUPERI 


OR    ASPECT    OF    THE    BRAIN     IN    A    CASE    OF    CHRONIC    DEMENTIA 
WITH    ATROPHY. 


PLATE    XXX  HI. 


(69) 


PLATE  XXXIII. 

Autopsy  No.   1793. 

mesial  surface  of  the  right  hemiem'ephalon  in  chronic  melancholia. 

Case  13814.  W.  G.;  aged  60;  white;  farrier;  nativity,  United  States.  Mental  disease, 
chronic  melancholia. 

Brain:  Weight,  1,270  grams.  Arteries  not  diseased;  pia  normal;  considerable  degree  of 
atrophy  of  the  anterior  portions.     No  lesions  in  the  interior. 

Heart:  Weight,  510  grams.  Chronic  disease  of  left  valves  and  interstitial  myocarditis 
affecting  the  anterior  wall  of  the  left  ventricle. 

The  kidneys  showed  some  interstitial  change  and  the  liver  some  cirrhosis. 

The  picture  is  mainly  of  anatomical  value,  the  only  pathological  feature  being  some  atrophy 
of  the  brain  anterior  to  the  paracentral  lobule.  The  section  cut  away  part  of  the  septum 
pellucidum  and  exposed  the  ganglia  of  the  right  lateral  ventricle.  Portions  of  both  sides  of  the 
septum  are  seen  remaining  anteriorly,  and  the  cavity  of  the  septum  pellucidum  is  thus  indi- 
cated.    The  other  parts  of  the  picture  are  self-explanatory. 

The  picture  shows  the  advantage  of  this  method  of  work  for  anatomical  illustrations. 

(70) 


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PLATE    XXXIV. 


(71) 
I  ToTs     os      -10 


PLATE  XXXIV. 

Autopsy  No.  2132. 

supebiob  sttrface  of  the  brain,  showing  arteriosclerotic  devastations  of  the  cortex. 

Case  9965.  C.  A.;  aged  74;  male;  colored;  nativity,  Virginia.  Mental  disease,  chronic 
melancholia,  with  arteriosclerotic  terminal  dementia.  The  patient  had  right  hemiplegia  since 
his  admission  in  July,  1896;  had  contractures  of  right  arm  and  leg.  Death  occurred  October 
14,  1906,  from  cystitis. 

Skull  unusually  thick,  being  2  centimeters  in  average  thickness  in  the  frontal  region. 
Numerous  nodular  exostoses  on  inner  surface  of  frontal  bone.     Dura  firmly  adherent. 

Brain:  Weight,  1,140  grams.  Marked  arteriosclerosis  and  some  minor  anomalies.  On  the 
left  side  the  brain  was  much  atrophied  and  the  surface  was  puckered  and  nodular.  There  was 
marked  shrinkage  and  sclerosis  of  the  lower  third  of  the  left  postcentral  gyrus,  all  of  the  pre- 
central  gyrus,  all  of  the  superior  frontal  gyrus  of  this  side,  the  insula,  anil  the  anterior  two-thirds 
of  the  mesial  surface  of  the  same  side.  Cortical  softenings  were  found  in  the  left  paracentral 
lobule,  the  middle  of  the  precentral  gyrus,  and  in  the  depth  of  the  central  fissure.  On  the  right 
side  there  was  some  sclerotic  atrophy  over  the  whole  frontal  lobe,  but  much  less  than  on  the 
left.  The  whole  brain  was  much  shrunken  and  the  sulci  were  widened.  Section  of  the  brain 
showed  no  softenings  involving  the  capsules  nor  basal  ganglia,  but  both  were  small  and  shrunken 
on  the  left  side,  presenting  a  marked  contrast  with  those  structures  on  the  right.  The  case 
seemed  to  be  one  of  cortical  origin  solely. 

The  lungs  showed  some  old  tuberculous  foci,  and  the  lower  lobes  of  both  were  solidified 
by  hypostatic  pneumonia. 

Heart:  Some  chronic  valvular  disease. 

Kidneys  showed  some  contraction;  pelvis  of  right,  catarrhal. 

Bladder  showed  adhesion  of  the  fundus  to  the  adjoining  peritoneum  by  plastic  adhesions; 
mucous  membrane  thickened  and  ulcerated.     Middle  lobe  of  prostate  gland  enlarged. 

The  liver  showed  passive  hyperemia. 

Other  organs  presented  nothing  worthy  of  note. 


GROSS   MORBID   ANATOMY   OF   THE   BRAIN    IN   THE   INSANE. 


PLATE   XXXIV. 


SUPERIOR   SURFACE   OF   THE   BRAIN,    SHOWING   ARTERIOSCLEROTIC    DEVASTATIONS 

OF    THE    CORTEX. 


PLATE   XX XV 


(73) 


PLATE  XXXV. 

Autopsy  No.  1990. 

a  dissection  showing  the  basal  arteries  and  the  atrophy  of  the  brain  in  the  region 

of  the  insure. 

Case  14645.  B.  A.;  age  26;  female;  colored;  nativity,  United  States.  Mental  disease, 
acute  mania;  physical  condition,  paresis  and  ataxia,  due  to  extreme  cerebral  atrophy  of  unknown 
origin. 

The  brain  weighed  990  grams.  Pia  slightly  cloudy;  cortex  dark  from  hypersemia;  great 
atrophy  of  entire  brain,  more  marked  in  the  region  of  the  insula  and  opercula  and  the  anterior 
portion  of  the  frontal  lobe.  The  arteries  at  the  base  showed  slight  opacity  in  patches  and  were 
unusually  small;  right  vertebral  artery  very  small  and  practically  obliterated. 

Other  organs  showed  nothing  of  importance. 

The  picture  shows  a  dissection  of  the  basal  arteries  made  by  removing  the  arachno-pia  and 
cutting  away  the  temporal  poles.  The  arteries  are  thus  exposed  and  unusual  atrophy  of  the 
insular  regions  is  demonstrated.  The  circle  of  Willis  is  seen  in  its  entirety,  and  the  internal 
nutrient  arteries,  the  anterior  choroid  vessels,  and  the  pontine  vessels  are  all  distinguishable 
with  the  aid  of  slight  magnification      The  cranial  nerves  have  all  been  preserved. 

The  cerebral  atrophy  is  noticeable  anteriorly.  It  is  possible  that  the  unusually  small 
vessels  and  the  cerebral  atrophy  are  anatomical  evidences  of  congenital  maldevelopment  rather 

than  acquired  disease. 

(74) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   XXXV. 


A    DISSECTION    SHOWING    THE    BASAL    ARTERIES    AND    THE    ATROPHY    OF    THE    BRAIN 

IN    THE    REGION    OF    THE    INSUL/E. 


PLATK    XXXVI. 


(75) 


PLATE  XXXVI. 

Autopsy  No.  1956. 

horizontal  section  of  a  brain  from  a  case  of  senile  dementia. 

Case  12526.  T.  S.;  aged  79;  white;  soldier;  nativity,  Ireland.  Mental  disease,  senile 
dementia.     Clinical  history  of  cardiac  valvular  disease,  with  hypertrophy. 

Brain:  Weight,  1,210  grams.  Cerebro-spinal  fluid  greatly  increased;  convolutions  atro- 
phied; pia  (edematous  and  opaque;  arteries  at  the  base  showed  some  opaque  patches  and  were 
somewhat  dilated  and  tortuous. 

The  picture  shows  a  horizontal  section  made  on  a  line  with  the  summit  of  the  cerebellum 
and  passing  through  the  basal  ganglia  and  the  capsules  in  a  position  most  favorable  to  show 
their  relations.  In  addition  to  the  anatomical  points  shown,  the  enlarged  perivascular  spaces 
surrounding  the  central  nutrient  vessels  are  very  well  seen.  The  ventricles  are  moderately 
enlarged,  and  the  atrophy  of  the  convolutions  and  the  thalami  is  very  apparent.  The  massa 
intermedia  is  preserved  and  may  be  seen  stretching  across  the  third  ventricle. 

The  heart  weighed  420  grams.  The  tricuspid  valve  was  incompetent ;  mitral  and  aortic 
valves  thickened  and  calcareous;  muscular  papilla?  fibrous.  Kidney  showed  passive  congestion. 
Liver  tissue  presented  nutmeg  mottling;  capsule  adherent  to  the  diaphragm. 

Note. — This  was  a  fresh  section  afterwards  hardened.  In  some  respects  these  are  prefer- 
able to  sections  made  after  hardening.  The  slight  wrinkling  sometimes  shows  remarkably  well 
the  direction  of  certain  fibers — for  example,  those  of  the  optic  radiations. 

(76) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   XXXVI. 


HORIZONTAL    SECTION     OF    A    BR 


AIN     FROM     A    CASE    OF    SENILE    DEMENTIA. 


PLATE    XXXVII. 


(77) 


PLATE  XXXVII. 

Autopsy  No.  2051. 

a  horizontal  section  of  a  brain  of  syphilitic  dementia. 

Case  15663.  G.  H.;  aged  29;  white;  female;  nativity,  United  States.  Mental  disease, 
dementia,    attributed    to    syphilis.     The    patient    died    of   general    exhaustion    and    infectious 

nephritis. 

Brain:  Weight,  1,140  grams.  Some  atrophy  of  the  frontal  regions;  tissue  cedematous  and 
the  ventricles  a  little  enlarged.     The  cerebral  arteries  were  normal. 

The  picture  shows  a  very  slight  deviation  from  the  normal  and  is  mainly  of  anatomical 
value.  On  the  right  side  the  section  is  a  little  lower  than  the  left  and  gives  a  good  view  of  the 
basal  ganglia  and  capsules.  The  section  is  markedly  clear  in  detail  and  may  be  contrasted 
with  the  chronic  and  senile  cases. 

The  kidneys  were  enlarged,  the  cortex  swollen  and  grayish;  pyramids  dark  by  contrast. 

The  liver  showed  some  adhesions  of  capsule  to  the  diaphragm  anil  some  passive  hyperemia. 

Cyst  of  right  ovary  the  size  of  a  walnut. 

(78) 


GROSS  MORBID  ANATOMY  OF  THE  BRAIN   IN   THE  INSANE. 


PLATE   XXXVII. 


HORIZONTAL    SECTION     OF    A    BRAIN    OF    SYPHILITIC     DEMENTIA. 


PLATE 


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III. 


■ 


47078— OS 11 


PLATE  XXXVIII. 

Autopsy  Xo.  1588. 

brain  of  a  case  of  senile  dementia  in  a  patient  aged  99  years. 

Case  11844.  M.  W.;  aged  99:  female;  white;  nativity.  .Maryland.  Mental  disease,  senile 
dementia  of  approximately  twenty  years'  duration. 

Brain:  Weight,  1,135  grams.  The  organ  was  greatly  atrophied  ever  the  whole  convexity. 
Pia  oedematous  and  loose;  vessels  curved  and  elongated  and  showed  a  few  opaque  patches  of 
atheroma.  No  gross  lesions  in  the  interior  except  a  small  softening  in  the  lenticular  nucleus  of 
the  left  side. 

The  picture  shows  the  extreme  shrinkage  of  the  convolutions  and  the  tortuosity  of  the 
arteries  and  veins.  The  photograph  was  taken  after  the  brain  was  hardened,  and  therefore  the 
looseness  of  the  pia  is  more  perceptible  than  in  the  fresh  condition.  The  cerebellum  is  out  of 
proper  position,  hut  the  atrophy  of  this  part  is  well  shown. 

The  skull  was  a  little  thicker  than  normal,  and  on  the  inner  surface  of  the  bone  on  the  left 
side  were  some  irregular  exostoses:   the  dura  was  firmly  adherent  to  the  bone. 

The  lungs  showed  pneumonic  consolidation  affecting  the  whole  of  the  lower  lobe  and  the 
lower  part  of  the  upper  lobe  of  the  left  lung,  and  slight  hypostasis  of  right  lung. 

(80) 


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PLATO   XXXIX. 


(81) 


PLATE  XXXIX. 

Autopsy  No.  2265. 

lateral  surface  of  the  left  hemiencephalon  in  a  case  of  chronic  melancholia. 

Case  12079.  P>.  D. :  aged  74 J;  white;  male:  nativity,  Germany.  Mental  disease,  chronic 
hallucinatory  melancholia;  duration,  seven  years.  The  patient  had  been  blind  and  deaf  for  the 
two  years  previous  to  his  death.  There  was  a  progressive  mental  deterioration  for  some  time. 
Patient  found  dead  in  his  bed  in  the  morning. 

Brain:  Weight,  1,290  grams.  There  was  a  thin  neomembrane  of  internal  pachymeningitis 
over  the  convexity  of  the  dura.  Pia  mater  cloudy  over  the  convexity;  very  slight  shrinkage 
of  the  brain.  Arteries  showed  some  minor  anomalies,  and  were  slightly  sclerotic.  Ventricles 
normal. 

The  picture  was  introduced  for  comparison  with  the  cases  of  cerebral  atrophy.  Though 
the  patient  was  well  advanced  in  years,  the  cerebral  arteries  were  nearly  normal  and  the  brain 
but  slightly  shrunken.  The  weight  was  about  113  grams  less  than  the  normal  average,  but  it 
did  not  show  so  much  reduction.  There  were  also  no  gross  lesions  to  account  for  the  loss  of 
sight  and  hearing,  so  that  these  affections  must  have  been  peripheral. 

The  heart  valves  were  all  competent,  except  some  slight  sclerosis  of  the  mitral,  with  some 
thickening,  and  slight  thickening  of  the  aortic  valves.  Weight  of  heart,  330  grams.  Slight 
atheroma  of  the  abdominal  portion  of  the  aorta. 

The  stomach  was  greatly  dilated  and  the  mucous  membrane  mammillated ;  walls  thin. 
Transverse  colon  was  elongated  and  dilated. 

The  cause  of  death  was  obscure,  but  the  conclusion  was  reached  that  it  must  have  been 
acute  gastric  dilatation,  with  cardiac  paralysis,  as  the  clinical  history  showed  that  the  heart 
was  functionally  disturbed.       . 

(82) 


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(83) 


PLATE  XL. 
Autopsy  No.   I!i40. 

THE    SUPERIOR    SURFACE    OF    THE    BRAIN    IN    CHRONIC    MANIA. 

Case  2878.  L.  McN.;  aged  60;  white:  male;  nativity,  Ireland.  Mental  disease,  chronic 
mania. 

The  brain  showed  slight  oedema  of  the  pia  and  a  little  separation  of  the  convolutions.  A 
few  patches  of  atheroma  in  the  cerebral  arteries  at  the  base.  The  lungs  showed  some  chronic 
tubercular  lesions  in  the  left  and  some  tubercular  cavities  in  the  right,  in  one  of  which  a  rupture 
of  a  vessel  had  caused  fatal  pulmonary  hemorrhage. 

The   picture   shows   the   superior  surface   of   the   brain   apparently   normal.     It   may  be 
contrasted  with  No.  1805,  Plate  XXX,  which  shows  senile  atrophy  in  a  man  aged  77  years. 

(84) 


GROSS  MORBID  ANATOMY  OF  THE  BRAIN   IN   THE  INSANE. 


PLATE   XL. 


THE    SUPERIOR    SURFACE    OF    THE    BRAIN     IN    CHRONIC    MANIA. 


PLATE    ALL 


85 


PLATE  XLI. 
Autopsy  No.   1693. 

the  effects  of  removal  of  the  p1a  in  paresis. 

Case  12545.  J.  V.  B.;  aged  25;  white;  soldier;  nativity,  Maryland.  Mental  disease, 
paresis,  of  about  two  years'  duration.  Brain  affection  said  to  he  due  to  injury  to  spine,  but  of 
this  the  history  was  indefinite.  Symptom-complex  of  paresis  typical;  occasionally  epileptiform 
convulsions,  more  severe  in  the  upper  extremities;  these  were  followed  by  transitory  increase 
of  the  paralytic  symptoms. 

Synopsis  of  autopsy:  Calvaria  thin;  persistent  frontal  suture;  dura  normal. 

Brain  weighed  1,200  grams.  Subarachnoid  fluid  much  increased;  convolutions  atrophied: 
brain  substance  oedematous  and  soft.  Gray  matter  everywhere  had  a  dark  violaceous  gray  hue; 
white  substance  on  section  dripped  with  moisture.  The  ventricles  slightly  dilated,  the  ependyma 
granular,  especially  in  the  fourth. 

Removal  of  the  pia  showed  almost  universal  adhesions  and  typical  decortication  of  the 

upper  layers,  perhaps  most  marked  over  the  inferior  parietal  lobule  and  the  temporal  lobe  and 

least  over  the  superior  central  regions.     The  large  arteries  at  the  base  showed  no  appreciable 

disease. 

(86) 


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PLATE    XL  II. 


(87) 
47078—08 12 


PLATE  XLII. 
Autopsy  No.  1695. 
the  left  hemisphere  in  a  case  of  paresis  "with  flaking  of  the  cortex. 

Case  12739.  L.  V.  B.;  aged  61;  white;  piano  tuner;  nativity,  Germany.  Mental  disease, 
paresis;  duration,  one  and  a  half  years. 

The  clinical  history  a  typical  symptom-complex  of  paresis;  supposed  cause,  alcoholism  (?). 

Synopsis  of  the  autopsy:  Brain  weight,  1,240  grams.  The  arachno-pia  was  thick  and 
opaque  over  the  convexity  and  the  anterior  portions  of  the  mesial  surfaces.  The  subarachnoid 
exudate  over  the  convexity  was  somewhat  opaque  and  patchy  in  character.  Veins  moderately 
full  of  blood;  arteries  apparently  normal.  The  frontal  lobes  were  adherent  below  by  their 
mesial  surfaces,  and  there  were  universal  adhesions  to  the  cortex,  resulting  in  the  removal 
of  the  outer  layers  of  the  cortex  witli  the  pia.  The  gray  substance  everywhere  was  darker 
than  normal  and  soft.     The  ventricles  were  normal  in  size;  ependyma  granulated. 

Some  old  tubercular  lesions  at  apices  of  lungs,   and  a  hypostatic  condition  posteriorly. 

Other  organs  showed  no  important  pathological  conditions. 

(88) 


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PLATE    XLTII. 


(89) 


PLATE  XLTII. 

Autopsy  Xo.  2()(iS. 

THE    RIGHT    IIEMIENCEPIIALON    IN    A    CASE    OF    PARESIS. 

Case  14172.  A.  II.;  aged  37;  male;  colored;  laborer;  nativity,  Maryland  Mental  dis- 
ease, paresis.     Symptoms  characteristic  of  the  disease.     Died  in  epileptiform  convulsions. 

Brain:  Weight,  1,140  grams.  Arachno-pia  cloudy  and  cedematous.  Some  shrinkage  of 
the  convolutions  over  the  convexity.  The  arteries  showed  slight  opacity  in  patches;  right 
vertebral  artery  small;  the  left  as  large  as  the  basilar,  both  posterior  communicating  arteries 
were  rather  larger  than  normal.     Ventricles  dilated  and  granulated. 

The  picture  shows  that  adhesions  of  the  pia  to  the  cortex  were  found  almost  everywhere, 
but  were  more  marked  over  the  frontal  lobes.  The  gray  matter  was  darker  than  normal. 
Section  of  the  organ  showed  oedema  and  widening  of  the  perivascular  spaces,  giving  in  some 
places  almost  a  cribriform  appearance  to  the  tissue. 

The  other  organs  presented  nothing  of  importance  in  this  connection. 

The  microscope  in  this  case  showed  typical  conditions  such  as  are  found  in  paresis. 

(90) 


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(91) 


PLATE  XLTV. 

Autopsy  No.   1.502. 
brain   showing  chronic  internal  hydrocephalus. 

Case  2281.  J.  II.;  aged  57;  male;  white;  nativity,  Germany.  Mental  disease,  chronic 
dementia;  duration,  thirty-five  years. 

Skull  was  very  thin,  almost  oval  in  outline:  sutures  partly  obliterated. 

Brain  weighed  1,04(1  grams:  each  half  the  same.  On  opening  the  ventricular  cavity  a 
large  quantity  of  fluid  escaped  and  the  cerebrum  collapsed.  The  ventricular  cavities  were 
greatly  enlarged,  especially  the  lateral  ventricles.  The  callosum  was  greatly  thinned,  in  some 
places  consisting  of  little  more  than  the  ependyma  and  pia.  Basal  ganglia  not  much  flattened. 
Foramen  interventriculare  greatly  enlarged ;  fornix  and  septum  much  atrophied,  and  the  latter 
was  in  some  places  deficient,  so  that  the  ventricular  cavities  were  in  direct  communication. 
The  third  and  fourth  ventricles  were  only  slightly  dilated;  the  intraventricular  veins,  especially 
the  striate  veins,  were  enlarged  and  prominent.  The  brain  mantle  was  in  some  places  not 
over  one-half  centimeter  in  thickness;  convolutions  atrophied,  but  not  flattened;  nor  were 
the  sulci  obliterated,  as  in  the  chronic  congenital  form  of  hydrocephalus.  Arteries  at  the  base 
not  diseased. 

The  condition  of  other  organs  not  important  in  this  connection. 

The  picture  shows  most  of  the  pathological  conditions  above  given,  and  gives  a  good  view 
of  the  relative  size  of  the  ventricle,  as  the  picture  is  taken  somewhat  less  than  natural  size. 
The  cavity  was  lightly  packed  with  cotton  before  hardening,  but  some  flattening  of  the  small 
parts  occurred;  these  have  been  corrected  in  the  finished  picture. 

(92) 


1 


PLATE    XLV. 


(93) 


PLATE  XLV. 

Autopsy  No.  1900. 

chronic  acquired  internal  hydrocephalus. 

Case  13210.  F.  T.;  male;  aged  79;  white;  nativity,  Germany;  occupation,  varnisher. 
Mental  disease,  senile  dementia. 

The  brain  was  much  atrophied,  especially  over  the  mesial  surface  of  the  frontal  lobes. 
Ventricles  dilated.  Some  sclerosis  of  cerebral  arteries.  Associated  pathological  conditions 
were  anchylosis  of  the  fourth,  fifth,  and  sixth  cervical  vertebrae,  slight  chronic  disease  of  the 
cardiac,  valves,  and  some  interstitial  change  in  the  kidneys. 

The  picture  shows  a  mesial  section  of  the  brain  and  the  dilated  right  lateral  ventricle, 
exposed  by  a  vertical  cut  made  about  1^  cubic  centimeters  outside  of  the  median  edge  of  the 
hemisphere  and  removing  this  piece  by  a  horizontal  cut  in  the  frontal  region  after  having  cut 
the  piece  free  posteriorly.  The  size  of  the  ventricle,  1  he  dilated  branch  of  the  striate  vein,  and 
the  caudate  nucleus  are  well  shown.  The  section  of  the  cerebellum  is  a  fortunate  one,  show- 
ing all  the  divisions  of  the  vermis  and  an  unusually  good  section  of  the  inferior  medullary  velum. 
The  massa  intermedia  was  absent,  as  it  frequently  is  in  extreme  enlargement  of  the  ventricles. 

(94, 


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17117  s  _08 13 


PLATE    XLVT  . 
Autopsy  No.  714. 
chronic  acquired  internal  hydrocephalus. 

Case  7656.  J.  P.  M.;  aged  60;  male;  white;  married;  nativity,  Ireland.  Mental  disease, 
chronic  dementia  :  duration,  seven  years.  The  cause  of  death  was  acute  colitis  and  tuberculous 
ulceration  of  the  ileum. 

Skull  very  thin;  antero-posterior  diameter,  21.5  centimeters;  transverse,  16  centimeters. 
Shape  symmetrical;  sutures  all  distinct.     Dura  normal. 

Brain:  Weight,  1,386  grams.  The  ventricles  contained  577  cubic  centimeters  of  fluid; 
they  were  greatly  dilated;  septum  pellucidum  thinned  and  almost  destroyed;  fornix  thinned; 
foramen  interventriculare  enlarged;  callosum  very  thin;  anterior  commissure  exposed  for  about 
1  centimeter;  third  ventricle  enlarged;  massa  intermedia  had  disappeared.  The  velum  inter- 
positum  was  thickened;  ependyma  thickened;  the  ventricular  veins  somewhat  prominent. 
Several  small  arteriosclerotic  softenings  in  the  caudate  nuclei.  The  gyri  on  the  convexity 
showed  some  flattening  from  increased  pressure. 

The  ileum  showed  several  chronic  tuberculous  ulcers  and  adhesions  of  the  serous  surface. 
The  large   intestine  showed   the   usual   lesions  of  acute  colitis. 

The  condition  of  the  other  organs  was  unimportant. 

(96) 


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(97) 


PLATE   XLVri. 
Autopsy  X<>.  606. 

A    CASK    OF    CHRONIC    ACQUIRED    CIRCUMSCRIBED    INTERNAL,    HYDROCEPHALUS. 

Case    3282.     J.    G.;  aged    52;  white:  male:  soldier;  nativity,    Ireland.     Mental    disease, 
chronic  epileptic  insanity;   duration,   twenty-five  and   one-half  years. 

Brain:  Weight  of  left  half,  610  grams;  the  right  half,  368.5  grams.  The  right  hemisphere 
was  occupied  by  a  large  cyst  like  accumulation  of  clear  fluid,  measuring,  together  with  the  con- 
tents of  the  ventricles,  385  cubic  centimeters.  The  dilatation  involved  nearly  all  of  the  parietal, 
temporal,  and  occipital  lobes,  and  the  brain  substance  over  this  region  was  very  thin.  The 
cavity  communicated  with  the  ventricle  by  a  large  opening  in  the  posterior  portion;  the  inner 
wall  of  the  cavity  was  covered  by  shreds  of  atrophied  brain  tissue,  and  the  course  of  some  of  the 
principal  fissures  could  be  seen.  The  brain  externally  showed  some  flattening  of  the  convolu- 
tions over  both  sides,  though  the  ventricle  of  the  left  side  was  only  moderately  dilated.  The 
brain  tissue  was  soft,  cortex  rather  dark,  a  few  small  softenings  in  the  caudate  nuclei,  and  slight 
arteriosclerosis.     The  fornix,  septum  pellucidum,  and  other  internal  parts  of  the  brain  seemed 

normal. 

(98) 


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99 


PLATE  XLVm. 
Autopsy   No.  162S. 

TRANSVERSE    SECTION   OF  THE    BRAIN,    SHOWING   CHRONIC    INTERNAL   HYDROCEPHALUS,    PROBABLY 

CONGENITAL. 

Case  13081.  E.  V.  C;  aged  59;  male;  white;  soldier:  nativity,  United  States.  Mental 
disease,  senile  dementia  The  clinical  symptoms  were  a  simple  form  (if  dementia,  supposed  to 
be  presenile.     Death  from  traumatic  pleuritis. 

Skull  thin;  frontal  suture  still  persistent,  somewhat  enlarged. 

Brain:  Weight  when  emptied,  1,560  grams:  ventricles  contained  340  cubic  centimeters  of 
fluid.  Convolutions  not  appreciably  flattened;  arteries  normal.  Ventricles  dilated;  callosum 
thinned;  anterior  white  commissure  exposed  for  about  2  centimeters  of  its  length;  massa  inter- 
media gone;  anterior  columns  of  the  fornix  elongated  and  cordlike;  septum  pellucidum  thin 
and  represented  by  some  ragged  strands.  The  basal  ganglia  were  flattened,  the  third  ventricle 
enlarged,  and  the  tidier  einereum  was  bulged  downward. 

The  patient  had  a  large  number  of  rib  fractures,  some  old  and  healed,  some  recent  and 
partially  displaced.  From  these  fractures  an  acute  pleuritis  had  developed,  and  the  lungs  were 
partly  solidified  by  pneumonic  exudate.  No  cause  was  discovered  for  the  rib  fractures,  except 
that   the  ribs  were  unusually  fragile. 

Other  organs  presented  nothing  of  importance. 

i  mill 


PLATE    XLIX. 


(101) 


PLATE  XLIX. 

Autopsy  No.  1934. 

horizontal  section  of  a  brain  from  a  case  of  senile  dementia  with  ventricular 

dilatation. 

Case  12.341.  A.  J.  B.;  aged  74:  white;  soldier;  nativity,  Ohio.  Mental  disease,  senile 
dementia.     Terminal  pneumonia  and  cardiac  weakness  terminated  life. 

Brain:  Weight,  1,210  grams.  Convolutions  extremely  shrunken  and  the  parts  at  the  base 
atrophied.  The  arteries  contained  numerous  patches  of  atheroma.  Pia  loose  and  cedematous; 
veins  moderately  full  of  blood. 

The  picture  shows  the  surface  atrophy  in  the  outline  and  in  the  widely  separated  gyri. 
The  ventricles  are  dilated,  especially  the  posterior  horn  of  the  left  lateral,  which  reaches  far 
into  the  occipital  lobe.  The  taeniae  fornicis  are  thinned  and  their  edges  are  covered  by  the 
borders  of  the  enlarged  choroid  plexuses.  The  enlarged  and  tortuous  choroid  vein  is  especially 
well  seen  on  the  right,  and  a  cluster  of  grapelike  cysts  of  the  plexus  are  seen  near  the  entrance 
of  the  inferior  horn  of  the  ventricle.  The  thinned  septum  pellucidum  and  the  edge  of  the 
fornix  where  it  joins  the  callosum  are  evidences  of  pressure  atrophy.  A  small  triangular  open- 
ing accidentally  made  through  the  corpus  fornicis  reveals  the  underlying  tela  chorioidea  ven- 
triculi  tertii. 

The  condition  of  the  other  organs  was  not  important  in  this  connection. 

JUL', 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   XLIX. 


HORIZONTAL    SECTION     OF    A    BRAIN     FROM    A    CASE    OF    SENILE    DEMENTIA    WITH 

VENTRICULAR     DILATATION. 


PLATE   L. 


(103) 
1707S     OS     —14 


PLATE  L. 

Autopsy  No.  2187. 

a  case  of  chronic  congenital  internal  hydrocephalus. 

Case  11547.     L.  P.;  aged  60;  male;  white;  single;  nativity,  District  of  Columbia.     Mental 

disease,  imbecility. 

The  patient  had  at  one  time  considerable  intelligence.  He  had  some  musical  ability,  some 
education,  and  could  converse  with  ordinary  facility  on  cm-rent  topics.  Later  in  life  be  became 
deeply  demented,  physically  helpless,  blind,  and  partially  deaf.  He  had  some  spasticity  of  the 
lower  limbs  and  beginning  contractures  of  knee  and  hip.  He  never  had  convulsive  attacks, 
and  aside  from  the  brain  disease  his  health  had  always  been  fair. 

The  skull  measured  in  circumference  70.5  centimeters;  biparietal  diameter,  19.6  centi- 
meters; and  from  ophryon  to  maximum  occipital  point,  23.3  centimeters.  The  skull  was 
unusually  thick  for  a  hydrocephalic,  measuring  an  average  of  1.6  centimeters  in  the  frontal 
regions.     Dura  mater  not  abnormally  adherent. 

Brain:  Weight  when  emptied,  1,240  grams.  It  contained  2,400  cubic  centimeters  of  fluid. 
Over  the  frontal  regions  of  brain  the  gyri  and  sulci  were  fairly  distinct,  but  over  the  posterior 
regions  the  configuration  was  lost  and  the  brain  mantle  was  converted  into  a  smooth  bag  of 
fluid,  the  walls  of  which  were,  in  places,  not  over  0.4  of  a  centimeter  in  thickness.  Section 
showed  that  the  dilatation  of  the  ventricles  was  principally  posteriorly,  a  fair  degree  of  thick- 
ness persisting  in  the  frontal  regions.  In  the  interior  it  was  found  that  the  posterior  and  lat- 
eral horns  of  the  ventricles  were  practically  merged  into  one,  the  septum  pellucidum  was  lost, 
basal  ganglia  were  flattened,  and  the  choroid  plexuses  were  pale  and  flattened.  On  the  right 
side,  where  the  section  passed  a  little  lower,  the  caudate  and  lenticular  nuclei  ami  the  internal 
capsule  were  still  distinguishable.  The  callosum  was  very  thin  and  separated  from  the  fornix; 
the  velum  interpositum  still  present  ;  third  anil  fourth  ventricles  slightly  dilated. 

The  relatively  better  preservation  of  the  frontal  lobes  was  noticeable  on  section,  and  the 
cortex  over  this  part  of  the  brain  was  of  normal  thickness.  In  fact,  the  whole  extent  of  the 
cortex  was  fairly  well  preserved,  the  extreme  dilatation  being  at  the  expense  of  the  white 
matter. 

The  basal  view  showed  a  disproportion  between  the  cerebellum  and  the  cerebrum,  some 
thickening  of  the  arachnoid,  normal  arteries,  and  the  optic  nerves  shrunken  and  grayish  in 
color. 

The  other  organs  showed  nothing  of  interest  in  this  connection. 

The  chief  interest  in  tins  case  was  the  preservation  of  a  degree  of  intellect,  doubtless 
correlated  with  the  better  preservation  of  the  frontal  lobes,  the  thickness  of  the  skull,  and 
the  preservation  of  an  almost  normal  shape  of  the  face. 

This  picture  shows  the  superior  surface  of  the  convexity.  Additional  illustrations  of  this 
case  are  given  on  Plates  LI  and  LII. 

(104) 


GROSS   MORBID   ANATOMY   OF   THE   BRAIN    IN   THE    INSANE. 


A    CASE    OF    CHRONIC     CONGENITAL     INTERNAL     HYDROCEPHALUS. 


PLATE    LI. 


(105) 


PLATE  LI. 

Autopsy  No.  2187a. 

a  case  of  chronic  congenital  internal  hydrocephalus  interior  of  basal  portion. 

Case  11547.     A  view  of   the  lower  part   of  the  interior  of   the  brain.      The  thickened 
ependyma  and  the  white  matter  have  separated  to  some  extent  from  the  cortex. 
A  general  discussion  of  this  case  is  given  on  page  104. 

(106) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


A    CASE    OF    CHRONIC    CONGENITAL     INTERNAL     HYDROCEPHALUS. 
Interior  of  basal  portion. 


PLATE    LII. 


(107) 


PLATE  LII. 

Autopsy  No.  2187b. 

a  case  of  chronic  congenital  internal  hydrocephalus  interior  of  upper  portion. 

Case   11547.      Interior  view  of  the  upper  portion  of  the  brain  within  the  calvaria.     The 
relatively  thick  cut  edge  of  the  skull  bone  may  be  seen.     The  dura  has  been  removed. 
A  general  discussion  of  this  case  is  given  on  page  104. 

(108) 


GROSS  MORBID  ANATOMY  OF  THE  BRAIN   IN   THE   INSANE. 


A    CASE    OF    CHRONIC    CONGENITAL    INTERNAL    HYDROCEPHALUS. 
Interior  of  upper  portion. 


PLATE   LIII. 


(109) 


PLATE  LIII. 

Autopsy  No.  1700. 

the  superior  surface  of  a  brain  showing  leptomeningitis. 

Case  2744.  E.  B. ;  aged  6S;  female;  white;  nativity,  Germany.  Mental  disease,  chronic 
mania. 

Synopsis  of  autopsy:  On  opening  the  dura  a  neomembrane  of  pachymeningitis  interna  was 
found  over  the  portion  of  the  dura  covering  the  convexity,  and  over  the  whole  extent  of  the  pia 
was  a  subarachnoid  sero-purulent  exudate.  Adhesions  had  formed  between  the  inflamed 
■arachno-pia  and  the  neomembrane.  The  brain  weighed  960  grams.  The  pia  over  almost  the 
whole  convexity  was  thick,  with  a  yellowish-white  exudate  in  its  meshes.  The  greatest 
intensity  of  the  condition  was  over  the  anterior  lobes,  the  right  convexity,  and  in  the  vicinity 
of  the  chiasma.  The  arteries  were  apparently  normal  on  the  convexity,  but  at  the  base  there 
was  some  sclerosis  and  the  right  vertebral  artery  was  small  and  partially  obstructed;  the  veins 
were  prominent  and  showed  as  dark  tortuous  lines  over  the  yellowish-white  exudate. 

An  additional  illustration  of  this  case  is  given  on  Plate  LIV. 

(110) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE  INSANE. 


IV 


THE    SUPERIOR    SURFACE    OF    A    BRAIN     SHOWING     LEPTOMENINGITIS. 


PLATE    LTV 


da) 


17078     08 15 


PLATE  L1V. 

Autopsy  No.   1700a. 

the  inferior  surface  of  a  brain  showing  leptomeningitis. 

Case  2744.  This  plate  shows  the  base  of  the  same  brain  with  the  prominent  veins  and 
t he  thickened  pia  and  arachnoid. 

The  lungs  showed  solidification  of  the  whole  lower  lobe  of  the  left  and  some  remains  of 
chronic  tuberculosis  of  the  apices.  The  kidneys  showed  slight  evidences  of  swelling  and 
probably  parenchymatous  inflammation. 

Other  organs  presented  nothing  important. 

A  general  discussion  of  this  case  is  given  on  page  110. 

(112) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


■  >        cv 


«F 


:^P" 


THE    INFERIOR    SURFACE    OF    A    BRAIN     SHOWING     LEPTOMENINGITIS. 


PLATE    LV. 


(113) 


PLATE  LV. 

Autopsy  No.  1941. 

a  brain  showing  chronic  meningeal  thickening  and  atrophy  consequent  iton  bullet 

wound  of  head. 

Case  13037.  J.  K.;  aged  67;  white;  cooper:  nativity,  Ohio.  Mental  disease,  chronic 
dementia.     Clinical  history  of  advanced  dementia,  delusions,  and  extreme  muscular  enfeeblement. 

Brain:  Weight,  1,080  grams.  Arteries  atheromatous  and  calcified;  softenings  found  in  the 
base  of  the  right  occipital  and  temporal  lobes,  on  the  external  surface  of  the  left  occipital  lobe, 
and  temporal  lobe.  Brain  excessively  atrophied  over  the  convexity,  pia  arachnoid  much 
thickened  over  the  fronto-parietal  convexity,  and  the  membrane  was  raised  by  large  subpial 
effusions.  Cerebellum,  pons,  and  medulla  were  much  shrunken.  (It  was  noted  that  the  large 
softening  of  the  brain  on  the  left  side  was  situated  beneath  the  site  of  the  wound  of  the  scalp. 
The  picture  does  not  show  the  softenings  of  the  cortex.) 

The  condition  of  the  other  organs  was  not  of  any  special  importance  in  this  connection. 
The  kidneys  showed  some  interstitial  changes,  there  was  some  interstitial  myocarditis,  and 
there  were  some  old  tubercular  lesions  of  the  apices  of  the  lungs. 

(J14) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


A    BRAIN    SHOWING    CHRONIC     MENINGEAL    THICKENING    AND    ATROPHY 
CONSEQUENT     UPON     BULLET    WOUND    OF    HEAD. 


PLATE    LVL 


(115) 


PLATE  LVL 

Autopsy  No.  1847. 

the  right  hemiencephalon  from  a  case  of  acute  mania. 

Case  14420.  A.  F. :  aged  20;  colored:  laborer:  nativity,  District  of  Columbia.  Mental 
disease,  acute  mania.  The  clinical  history  shows  that  the  patient  suffered  from  intense  maniacal 
excitement,  which  lasted  from  his  admission  four  days,  until  his  death  occurred. 

Synopsis  of  autopsy:  Brain,  weight  of  each  half,  790  grams,  or  1,580  grams  for  the  whole 
encephalon.     The  whole  brain  was  most  intensely  hyperaemic,  every  vessel  visible  to  the  naked 

eye  was  filled  with  I >  1 1,  and   the  gray  matter  presented  a  deep  purplish  hue.     The  white 

matter  had  a  pinkish  hue,  and  the  whole  brain  was  oedematous  and  soft.  It  was  found  to  be 
impossible  to  remove  the  pia  without  lacerating  the  cortex,  but  there  were  no  other  signs 
of  meningo-encephalitis.  The  pia,  aside  from  the  intense  hyperemia,  did  not  show  any  signs 
of    inflammation. 

The  lungs  showed  acute  caseous  tuberculous  masses,  and  the  bronchi  were  full  of  muco- 
purulent secretions.  The  kidneys  and  liver  were  intensely  hypersemic.  No  cause  could  be 
discovered  for  the  condition  except  the  suggestion  of  some  acute  toxaemia,  possibly  tubercular. 

(116) 


h- 

5 


i 


PLATE   LVII. 


(117) 


PLATE  LVn. 

Autopsy  No.  10')"). 

the  superior  aspect  ok  the  brain  in  a  case  ok  extreme   meningeal  hyper.emia  with 

chronic  (edema. 

Case  8102.  A.  W. ;  aged  32;  white;  soldier;  nativity,  California.  Mental  disease,  chronic 
melancholia.     Extreme  restlessness;  did  not  sleep  well;  mental  excitement. 

Brain :  Weight ,  1 ,280  grams.  The  pia  mater  over  the  whole  convexity  was  opaque,  thickened, 
and  (Edematous.  The  veins  were  deeply  engorged,  and  the  gray  matter  everywhere  was  red- 
dened and  soft.  The  arteries  were  not  diseased.  Cerebellum  deeply  hypersemic  and  its  veins 
and  arteries  full  of  blood.  Though  the  pia  was  not  removed,  a  considerable  degree  of  shrinkage 
was  noted  in  the  frontal  regions. 

The  liver,  spleen,  and  kidneys  were  congested,  due  doubtless  to  disease  and  incompetency 
of  the  tricuspid  valve.     Other  cardiac  valves  were  normal. 

Stomach  showed  the  effects  of  chronic  catarrh,  and  the  solitary  follicles  of  the  small  intestine 
were  enlarged. 

Note. — The  symptoms  were  those  of  cerebral  hypersemia  with  prostration,  and  some  gastro- 
intestinal irritation  which  occasioned  vomiting. 

(118) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   LVII. 


THE    SUPERIOR    ASPECT    OF    THE    BRAIN     IN    A    CASE    OF    EXTREME    MENINGEAL 
HYPER/EMIA    WITH     CHRONIC    CEDEMA. 


PLATE    LVIII. 


(119) 


47117s—  08 16 


PLATE  LVIII. 

Autopsy  Xo.  2069. 

the  superior  aspect  of  a  brain  from  a  case  of  extreme  atrophy  in  the  terminal 

dementia  of  melancholia. 

Case  4850.  F.  B.;  aged  78;  female;  colored;  nativity,  Maryland.  Mental  disease, 
melancholia  with  arteriosclerotic  terminal  dementia;  duration,  twenty-six  years.  Pulmonary, 
and   more   or  less  generalized  tuberculosis. 

Synopsis  of  autopsy:  Brain  weighed  910  grams.  The  organ  was  much  shrunken  and  the 
pia  contained  a  large  accumulation  of  subarachnoid  fluid.  The  cerebral  arteries  were  small, 
distorted,  and  sclerotic.  The  inferior  cerebellar  artery  of  right  side  came  off  in  common  with 
the  anterior  cerebellar. 

The  picture  shows  the  general  atrophy  of  the  convolutions,  and  the  large  cerebral  veins. 
Those  of  the  right  side  are  unusual  in  arrangement. 

The  lungs  showed  old  tubercular  lesions  with  recent  auto-infection  of  the  remainder  of  the 
lungs.  The  peritoneum.  Fallopian  tubes,  and  kidneys  were  tubercular,  and  the  tubes  and  uterus 
were  filled  with  pus. 

Heart  small,  some  thickening  of  left  valves,  and  the  aorta  contained  a  few  patches  of 
atheroma. 

(120) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   LVIII. 


THE    SUPERIOR    ASPECT    OF    A    BRAIN     FROM     A    CASE    OF    EXTREME    ATROPHY 
IN     THE    TERMINAL     DEMENTIA    OF     MELANCHOLIA. 


PLATE    LI'X. 


121) 


PLATE  LIX. 

Autopsy  No.  2126. 

superior  surface  of  the  brain,  showing  engorgement  of  the  piae  veins. 

Case  15040.  M.  T. ;  a^ed  21;  female;  colored;  nativity,  District  of  Columbia.  Mental 
disease,  dementia  prsecox ;  duration,  nine  months.  The  patient  had  several  maniacal  attacks 
simulating  manic-depressive  insanity. 

Brain:  Weight,  1,340  grams — above  the  average  fur  adult  females,  which  is  1,247  grams. 
There  was,  however,  slight  atrophy  of  the  convexity,  probably  due  to  the  general  wasting  of 
the  body.  With  the  exception  of  this  slight  shrinkage  and  overfullness  of  the  veins  the  brain 
was  absolutely  normal  in  appearance,  and  the  picture  is  introduced  to  contrast  with  the  cases 
of  meningeal  disease,  extreme  atrophy,  and  disease  of  the  vessels. 

The  lungs  showed  gangrenous  areas,  cavities,  and  pneumonic  consolidation. 

Other  organs  showed  nothing  abnormal  to  unaided  eye. 

(122) 


GROSS  MORBIO  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   LIX. 


SUPERIOR    SURFACE    OF    THE    BRAIN,    SHOWING     ENGORGEMENT    OF    THE 

PIAL    VEINS. 


PLATE    LX. 


(123) 


PLATE  LX. 

Autopsy  Nos.  2183  and  2240. 

view  of   the  braes   iv  a  case  of  meningoencephalitis  of  childhood,  with  arrest  of 
development  of  the  brain.     photographed  with  a  brain  of  normal  size  and  weight. 

Case  15217.  M.  C.  H. ;  aged  16;  female;  white;  nativity,  United  States.  Mental  disease, 
imbecility  (?).  The  duration  was  uncertain.  Patient  had  convulsions;  was  blind;  unable  to 
talk:  had  marked  contractures  of  upper  and  lower  extremities. 

Skull  moderately  thick;  nearly  elliptical  in  shape;  tables  were  thin  and  hard;  diploe 
abundant.  Frontal  sinuses  enlarged;  greatest  thickness  of  frontal  bone  about  1J  centimeters. 
Sagittal  suture  partly  obliterated.  Dura  not  adherent  to  bone  and  otherwise  normal.  Cere- 
brospinal fluid  increased. 

Brain:  Weight,  720  grams;  the  right  hemisphere  somewhat  smaller  than  the  left.  The 
organ  was  everywhere  greatly  shrunken,  the  insula'  partly  exposed.  Pia  opaque  and  thick, 
with  whitish  lines  along  the  veins.  Vessels  moderately  full  of  blood;  arteries  normal.  The 
pia  arachnoid  was  thick  around  the  isthmus  encephali.  The  basal  parts  of  the  brain  were 
much  atrophied;  no  loss  of  substance  from  gross  lesions.  No  special  conditions  present  in 
the  optic  centers,  tracts,  nor  optic  nerves,  except  possibly  some  rigidity  of  the  free  portions. 
The  cerebellum  was  doubtless  somewhat  smaller  than  normal,  but  it  was  relatively  large  com- 
pared with  the  cerebrum.  Over  the  superior  and  posterior  parts  the  pia  was  thick,  opaque, 
and  cedematous.  The  conclusion  reached  was  that  the  patient  had  an  attack  of  meningo- 
encephalitis in  childhood   which  permanently  impaired  the  development  of  the  brain. 

Superior  surface  of  the  brain,  showing  the  pial  opacity  and  thickening  and  the  cerebral 
atrophy.  The  brain  of  No.  21S3  is  photographed  with  one  from  a  case  of  dementia  praecox 
(No.  2240),  of  about  the  normal  size  and  weight,  1,480  grams,  and  showing  no  evidence  of 
disease  to  the  naked  eye. 

An  additional  illustration  of  this  case  is  given  on  Plate  LXI. 

(124) 


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PLATE    LXI. 


(125) 


PLATE  LXI. 

Autopsy  No.  2183a. 

views  of  the  brain  in  a  case  of  meningoencephalitis  of  childhood,  with    arrest  of 

development  of  the  brain. 

Case  15217.     Mews  of  the  hemispheres  of  this  brain  divided  in  the  median  line  to  show 
the  atrophy  of  the  mesial  surfaces. 

A  general  discussion  of  this  ease  is  given  on  page  124. 

(126) 


§ 


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PLATE    LXIT. 


(127) 
47078  -08 17 


PLATE  LXII. 

Autopsy  No.  1946. 

the  superior  surface  of  a  brain  compressed  by  accumulation  of  subdural  fluid. 

Case  15022.  L.  A.;  aged  56;  female;  colored;  nativity,  United  States.  Mental  disease, 
organic  dementia.     Patient  had  choreiform  movements  of  the  extremities. 

Skull  fairly  thick  and  dense;  sutures  partly  obliterated.  On  opening  the  subdural  cavity 
210  cubic  centimeters  of  clear  fluid  escaped,  and  it  was  seen  that  the  brain  was  greatly  com- 
pressed, especially  anteriorly.  There  was  but  little  evidence  of  gaping  of  the  sulci,  and  the 
convolutions  were  actually  flattened  on  the  surface  and  pressed  against  the  falx.  The  brain 
weighed  only  800  grams.  The  arachno-pia  showed  marked  opacity  over  the  convexity  and  in 
the  vicinity  of  the  chiasms  and  interpeduncular  space.  The  pituitary  body  was  about  four 
times  its  normal  size.  The  veins  over  the  convexity  were  quite  distinct,  and  some  were  bor 
dered  by  whitish  lines.  The  arteries  showed  no  abnormal  conditions.  Careful  examination 
of  the  dura  failed  to  reveal  any  pathological  condition  except  adhesions  to  the  bone,  slight 
thickening,  and  rather  large  Pacchionian  granulations. 

The  cause  which  led  to  the  subdural  effusion  must  therefore  be  undecided. 

Other  organs  presented  nothing  important. 

(128) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   LXII. 


THE  SUPERIOR   SURFACE  OF  A   BRAIN   COMPRESSED   BY  ACCUMULATION 
OF    SUBDURAL    FLUID. 


PLATE    LXITT. 


(129) 


PLATE  LXTTI. 

Autopsy  No.  2006. 

the  superior  aspect  op  a  brain  showing  compression  of  the  left  hemisphere  by  a 

hematoma  of  the  dura. 

Case  10287.  J.  G.;  aged  69;  white;  soldier:  nativity,  Switzerland.  Mental  disease  on 
admission,  acute  dementia,  from  organic  disease  of  brain.  Patient  lived  about  eight  years 
after  admission:  had  convulsions;  became  more  demented,  and  finally  the  right  side  became 
paralyzed,  and  toward  the  end  he  was  stuporous  and  died  in  coma. 

Brain  and  dura:  On  the  left  side  a  bulky  hematoma,  about  an  inch  in  thickness,  occupied 
the  dura  over  the  convexity  and  greatly  compressed  the  hemisphere.  The  tumor  consisted  of 
at  least  two  well-defined  layers,  between  which  the  recent  hemorrhage  which  had  caused  the 
paralysis  had  occurred.     No  membrane  could  be  demonstrated  on  the  falx  nor  the  right  side. 

The  brain  showed  marked  compression,  especially  over  the  anterior  portions  of  the  con- 
vexity. The  veins  were  engorged  even  where  pressure  was  greatest.  Some  opacity  and  thick- 
ening of  the  pia  arachnoid  over  the  superior  portions  of  the  convexity,  and  the  convolutions 
showed  some  shrinkage.     Some  patches  of  arteriosclerosis  in  the  basal  vessels. 

Some  chronic  disease  of  the  cardiac  valves,  especially  the  aortic  segments. 

In  the  picture  an  attempt  was  made  to  show  the  distortion  of  the  left  hemisphere  by 
the  pressure  of  the  hasmatoma.  The  flattening  of  the  convexity  is  fairly  well  shown,  espe- 
cially the  deep  depression  of  the  extreme  frontal  end  of  the  hemisphere.  A  feature  to  be  noticed 
is  the  engorgement  of  the  cerebral  veins,  notwithstanding  the  great  degree  of  pressure.  This 
fullness  of  the  veins  must  be  mechanical,  though  the  mode  of  production  is  not  clear. 

(130) 


I- 
5 


- 

2 


PLATE    LXIV. 


(131) 


PLATE  LXIV. 

Autopsy   No.  '229. 

the  right  hemisphere  of  a  case  of  atrophic  sclerosis  in  epilepsy. 

Case  6860.  J.  II.;  aged  45;  male;  farmer:  nativity,  United  States.  Mental  disease, 
chronic  epileptic  dementia;  duration,  three  and  one-half  years. 

Synopsis  of  autopsy:  Skull  dense:  dura  adherent  over  inner  table.  Some  local  thicken- 
ing of  the  bone  at  the  two  sides  of  the  frontal  bone  and  the  upper  and  anterior  part  of  the  parietal 
bones. 

Brain:  Weight,  1,141  grams.  The  pia  mater  was  opaque  and  thickened  over  the  superior 
portions  of  the  brain;  veins  engorged.  Great  shrinkage  of  the  convolutions  over  the  greater 
part  of  the  convexity  except  the  Sylvian  regions  and  the  anterior  portions  of  the  temporal 
lobes.  On  the  mesial  surfaces  the  shrinkage  was  not  marked,  and  the  basal  surface  showed 
none  of  the  characteristic  shrinkage  and  puckering.  The  cerebral  arteries  showed  some  patches 
of  opacity  in  the  larger'  trunks. 

The  condition  of  the  most  affected  region  is  hard  to  describe.  Morphologically  the  sur- 
face suggested  that  of  the  surface  of  the  liver  in  cirrhosis.  There  was  marked  puckering  of  the 
surface,  some  brownish  staining  of  the  pits  or  depressions,  and  a  general  shrinkage  of  the  affected 
gyri.     The  microscope  showed  multiple  small  softened  areast  with  some  accompanying  sclerosis. 

Heart.     Weight,  436  grams.     Some  thickening  of  left  valves  and  mitral  incompetence. 

Kidneys  showed  advanced  chronic  interstitial  nephritis. 

(132) 


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PLATE    LXV. 


133) 


PLATE  LXV. 
Autopsy  No.  1951. 
the  superior  surface  of  a  brain  with  localized  sclerosis  of  left  frontal  lobe. 

Case  4547.  F.  L. ;  aged  46;  female;  colored;  nativity,  United  States.  Mental  disease, 
chronic  epileptic  dementia.  The  history  shows  progressive,  dementia;  extreme  contractures  of 
legs;  epileptic  attacks  infrequent ;  bedsores  finally  developed. 

Cranium:  The  skull  thick  in  frontal  regions  and  rough  and  irregular  on  the  inner  surface; 
frontal  sinuses  enlarged  and  filled  with  greenish  pus.     Some  small  masses  of  bone  in  the  dura. 

Brain:  Weight,  1,110  grams.  Vessels  at  the  base  not  diseased;  pia  nonadherent;  brain 
moderately  shrunken  generally,  and  a  region  in  the  middle  of  the  convex  surface  of  the  frontal 
lobe  was  markedly  indurated  and  slightly  puckered,  hut  there  were  no  adhesions  of  the  pia  to 
the  cortex. 

The  picture  shows  decided  disproportion  between  the  two  hemispheres,  and  on  the  outer 
surface  of  the  left  frontal  lobe  the  regions  of  sclerosis  may  be  seen.  On  the  right  side  the 
hemisphere  is  fairly  normal  in  appearance. 

The  other  organs  showed  nothing  of  special  importance  except  some  catarrh  of  the  urinary 

bladder. 

(134) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE  LXV. 


THE    SUPERIOR    SURFACE    OF    A    BRAIN     WITH     LOCALIZED    SCLEROSIS    OF 

LEFT     FRONTAL    LOBE. 


PLATE    LXVI. 


(135) 

I7M7S      nx  is 


PLATE  LXVI. 

Autopsy  No.  S(.)7. 

A    CASE    OF    SCLEROSIS    OF    A    PORTION    OF    THE    RIGHT    HEMISPHERE    IN    EPILEPSY. 

Case  867(1.  ELM.  B.;  aged  47;  male;  white;  soldier;  nativity,  Indiana.  Mental  disease, 
chronic  epileptic  dementia:  duration,  thirty  years.  The  history  in  this  case  is  meager,  and 
aside  from  the  i'aet  of  typical  epilepsy  of  long  duration,  hut  with  sufficient  intelligence  to  serve 
as  a  soldier  in  the  civil  war,  and  no  noticeable  physical  impairment,  we  have  nothing  definite. 
Death  due  to  organic  brain  disease. 

Skull  of  fairly  normal  shape  and  size,  but  dense  and  the  sutures  indistinct  in  inner 
table.     Dura  slightly  adherent  to  bone. 

Brain:  Weight  of  right  hemisphere,  517.4  grams;  left,  545.6  grams;  cerebellum,  pons,  and 
medulla,  184  grains.  Arteries  at  base  small,  but  otherwise  normal ;  brain  pale:  slight  general 
shrinkage.  On  the  right  side  a  large  puckered  and  nodular  depression  existed  in  the  supra- 
Sylvian  region.  The  lesion  involved  the  bases  of  the  middle  and  inferior  frontal  gyri,  the  lower 
two-thirds  of  the  central  gyri,  the  whole  of  the  supramarginal  gyrus,  a  portion  of  the  inferior 
parietal  lobule,  and  extended  on  to  the  insula.  There  was  some  overhanging  of  the  surrounding 
brain,  showing  that  the  lesion  was  of  long  standing,  probably  developmental.  The  pia  mater 
was  not  adherent  over  the  lesion,  though  mechanically  hard  to  remove  from  the  deeper  portions 
of  the  affected  sulci.  The  vessels  of  this  region  showed  nothing  to  which  the  alteration  could 
be  traced.  On  the  left  side  were  several  small  cortical  softenings  not  easily  explained.  No 
lesions  in  capsules  nor  basal  ganglia.  There  seemed  to  be  slight  atrophy  of  cms  and  pons  on 
the  right  side.     Spinal  cord  normal  to  naked  eye. 

Heart:  Slight  hypertrophy  and  valvular  disease,  with  incompetency. 

Other  organs  were  practically  normal. 

Note. — This  specimen,  occurring  in  an  epileptic,  was  almost  identical  macroscopically  and 
microscopically  with  that  of  No.  2283,  Plate  LXVII.  The  patients  were  nearly  the  same  age, 
and  in  each  the  disease  was  of  long  duration.  It  is  probable  that  in  both  cases  the  sclerosis 
was  of  a  developmental  type  and  the  anatomical  basis  of  the  epilepsy. 

(136) 


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(137) 


PLATE  LXVII. 

Autopsy  No.  2283. 

sclerosis  of  a  portion  of  the  right  hemisphere  in  epilepsy. 

Case  10008.  F.  B. ;  aged  45;  male:  colored;  nativity,  Maryland.  Mental  disease, 
chronic  epileptic  insanity;  duration  of  disease,  since  admission,  ten  years.  The  patient  had 
frequent  and  severe  convulsions,  followed  by  excitement,  during  which  he  was  combative  and 
threatening.  The  patient's  mother  stated  that  he  had  no  convulsions  before  he  was  23  years 
old.     Death  due  to  injury  to  head  during  an  epileptic  seizure. 

Brain:  Weight,  1,355  grams.  Some  subpial  hemorrhage,  with  laceration  of  the  brain 
cortex  over  the  right  temporal  lobe  and  a  small  softening,  with  loss  of  substance,  on  the  outer 
surface  of  the  right  temporal  pole.  In  the  region  of  the  right  Sylvian  fissure  was  a  large 
depression,  over  which  the  cortex  presented  a  nodular  puckered  appearance.  On  removal  of 
the  pia,  which  was  not  unusually  adherent  to  the  lesion,  the  condition  was  found  to  involve  the 
posterior  half  of  the  superior  temporal  gyrus,  the  whole  of  the  supramarginal  gyrus,  and 
extended  forward  into  the  base  of  the  third  frontal  gyrus  and  upward  into  the  lower  ends  of  the 
central  gyri,  especially  the  postcentral  gyrus.  It  also  extended  into  the  inferior  parietal  lobule 
and  encroached  to  a  slight  extent  upon  the  insula.  Around  the  edge  of  the  lesion  the  normal 
brain  substance  overhung  the  affected  area.  The  arteries  of  the  Sylvian  region  presented 
nothing  abnormal  in  development  and  the  vessels  were  not  diseased.  There  were  some  minor 
anomalies  of  the  arteries  at  the  base  and  slight  sclerosis  of  the  intracranial  portions  of  the 
carotids 

The  cranium  showed  an  irregular  fracture  extending  from  the  petrous  portion  of  the 
temporal  bone  to  near  the  apex  of  the  lambdoid  suture,  produced  by  a.  fall  during  a  convulsion. 

With  the  exception  of  intense  passive  hypersemia  the  other  organs  were  practically  normal. 

The  lesion  found  is  not  infrequently  met  with  in  epileptics.     It  belongs  to  the  class  known 

as  the  scleroses  and  may  affect  almost  any  part  of  the  brain.     It  would  seem  that  these  lesions 

are  in  some  instances  developmental  defects.     The  microscope  shows  almost  complete  absence 

of   nerve  cells  in   the   depressed   regions  and   an  irregular  arrangement   of   these   elements  in 

the  projecting  nodules  or  granulations.     (See  Nos.  220,  897,  and  1951,  Plates  LXIV,  LXVI, 

and  LXV.) 

(138) 


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(139) 


PLATE   LXVIII. 

Autopsy  Xo.  2283a. 

mesial  view  of  the  left  hemisphere,  showing  absence  of  the  septum  pellucidum. 

This  developmental  defect  occurred  in  the  same  case  as  the  sclerosis  of  the  right  hemi- 
sphere, and  while  it  probably  had  no  direct  connection  with  the  latter  it  is  some  indication  of  a 
defective  formation  of  the  brain.  There  was  no  trace  of  the  septum,  but  the  fornix  itself  appeared 
normal  and  the  ventricles  were  not  abnormally  enlarged.  The  picture  presents  no  other  points 
of  interest  except  an  unusual  calcarine  fissure  and  an  unusually  prominent  mesial  extent  of  the 
central  fissure.     (See  No.  1949,  Plate  LXIX.) 

(140) 


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PLATE    LXIX. 


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PLATE  LXIX. 

Autopsy  No.  1949. 

horizontal  section  of  a  brain  without  a  septum  pellucidum. 

Case  5191.  C.  S.;  aged  54;  male;  white;  convict;  nativity,  New  York.  Mental  disease, 
chronic  mania. 

The  brain  weighed  1,320  grams.  Some  oedema  of  pia;  slight  shrinkage  of  convolutions  of 
frontal  lobes.  Vessels  not  diseased.  Section  of  brain  made  after  hardening  showed  absence 
of  septum.     The  condition  of  other  organs  unimportant  in  this  connection. 

The  photograph  shows  the  lower  portion  of  the  cerebrum  divided  horizontally.  The  upper 
part  showed  the  under  side  of  the  callosum  with  two  antero-posterior  ribs,  indicating  the  remains 
of  the  septum,  anil  two  small  filaments,  scarcely  visible,  which  connected  these  with  the  corpus 
fornicis.  The  lower  portion  gives  a  view  of  the  fornix  without  the  vertical  connection  with  the 
calJosum.  The  taeniae  fornicis,  plexuses,  and  two  thick  bundles  anterior  to  the  foramen  inter- 
ventricular show  the  remains  of  this  system,  and  a  sharp  ridge  which  curves  upward  and 
appears  as  a  spine  on  the  anterior  portion  of  the  callosum  represents  the  trace  of  the  septum. 
Grapelike  cysts  of  the  plexuses  are  indistinctly  seen  in  the  posterior  horns  of  the  ventricles. 

(142) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN  THE   INSANE. 


PLATE   LXIX. 


HORIZONTAL    SECTION     OF    A    BRAIN    WITHOUT    A    SEPTUM     PELLUCIDUM. 


PLATE    LXX. 


(143) 


ITi'Ts      us  111 


PLATE  LXX. 
Autopsy  Xo.  1964. 

horizontal  section"  of  a  brain  made  on"  a  level  of  the  junction  of  the  fornix  with 

the  (  ai.i.osim. 

Case  3855.  P.  F.:  aged  57;  male:  white;  nativity,  Ireland.  Mental  disease,  manic- 
depressive  insanity:  duration,   two  months. 

The  brain  weighed  1,310  grams.  There  appeared  to  hi'  scarcely  distinguishable  atrophy 
of  the  convolutions  and  some  arteriosclerosis  of  the  cerebral  vessels;  otherwise  the  brain 
showed  no  gross  lesions.  Heart  enlarged;  weight.  490  grams.  Incompetency  of  auriculo- 
ventricular  valves:   ante-mortem  clot   in  right   ventricle. 

The  picture  shows  a  section  made  on  about  the  same  level  as  Xo.  l!)4fl,  Plate  LXIX,  and 
with  this  specimen  it  maybe  compared.  It  presents  no  pathological  alterations  of  importance 
and  is  mainly  an  anatomical  study.  A  few  small  cysts  of  the  choroid  plex uses  are  seen  near 
the  entrance  to  the   descending   horns   of   the   lateral   ventricles. 

(144) 


GROSS   MORBID  ANATOMY  OF  THE  BRAIN   IN   THE   INSANE. 


PLATE   LXX. 


HORIZONTAL    SECTION     OF    A    BRAIN     MADE    ON    A    LEVEL    OF    THE    JUNCTION    OF 
THE    FORNIX    WITH     THE    CALLOSUM. 


PLATE    LAW  I. 


(145) 


PLATE   LXXI. 

Autopsy  No.  1967. 

horizontal  section  of  a  brain  from  a  (ask  of  dementia  precox. 

Case  14470.  J.  W.  W.;  aged  20;  colored;  male:  nativity,  District  of  Columbia.  Mental 
disease,  dementia   prsecox.     Advanced  pulmonary  tuberculosis,  and  death  from  hemorrhage. 

Brain:  Weight,  1,400  grams.  Very  slight  shrinkage  <>n  the  surface  and  faint  cloudiness 
of  the  pia  arachnoid.     Arteries  normal. 

The  picture  is  chiefly  of  anatomical  interest,  no  pathological  alteration  being  apparent. 
It  is  introduced  mainly  to  contrast  with  Nos.  19:54,  1950,  Plate  XLIX,  XXXVI,  and  others, 
showing  abnormal  conditions,  and  to  show  the  normal  condition  of  the  septum   pellucidum. 

The  lungs  were  in  an  advanced  stage  of  destructive  tuberculosis,  and  in  the  small  intestine 
were  a  number  of  tubercular  ulcers. 

Kidneys  showed   a   slight    degree  of  parenchymatous  nephritis. 

Other  organs  presented  nothing  abnormal. 

(14(i) 


GROSS  MORBID  ANATOMY  OF  THE  BRAIN   IN   THE  INSANE. 


PLATE   LXXI. 


HORIZONTAL    SECTION    OF    A    BRAIN     FROM    A    CASE    OF    DEMENTIA    PR/tCOX. 


PLATE    LXXII 


147 


PLATE  LXXII. 

Autopsy  No.   1619. 

section  of  brain   showing  glioma  of  left  frontal  lobe. 

Case  632,s.  W.  L.;  aged  49;  soldier:  white ;  nativity, Germany.  .Mental  disease,  dementia 
from  tumor  of  brain. 

Brain:  Weight,  1,350  grams.  Brain  showed  the  effects  of  intracranial  pressure,  espe- 
cially over  the  left  frontal  lobe.  Case  reported  in  1902,  "Intracranial  Tumors  Among  the 
Insane." 

The  picture  shows  a  large  glioma  occupying  the  left  frontal  lobe.  Traces  of  the  cortex  and 
pia  may  be  seen  extending  over  the  outer  border  of  the  tumor.  The  dark  mottling  is  due  to 
hemorrhage  and  degeneration  of  large  areas  within  the  tumor.  The  tumor  has  enlarged  the 
frontal  operculum  and  pressed  backward  and  inward  upon  the  insula,  flattening  out  the  ante- 
rior insular  gyri,  though  the  cortex  is  not  destroyed.  The  basal  ganglia  are  thrust  inward  and 
the  septum  pellucidum  displaced  to  the  right.  The  disproportion  in  size  of  the  two  frontal  lobes 
is  marked.  In  the  left  lenticular  nucleus  a  small  area  of  softening  is  seen  and  perivascular 
spaces  around  the  central  nutrient  arteries  are  enlarged. 

The  arteries  at  the  base  showed  patches  of  atheroma  and  were  moderately  dilated  and 
curved.     Brain  tissue  in  the  vicinity  of  the  tumor  markedly  softened. 

(148) 


GROSS  MORBID  ANATOMY  OF  THE   BRAIN   IN   THE   INSANE. 


PLATE   LXXII. 


SECTION    OF    BRAIN    SHOWING    GLIOMA    OF    LEFT     FRONTAL    LOBE. 


PLATE    LXXIII. 


(149) 


PLATE   LXXIII. 

Autopsy  No.  2113. 

plate  showing  a  tumor  op*  the  dura   penetrating  the  brain*. 

Case  9110.  M.  T.  S. ;  aged  45£;  female:  white:  single1;  nativity,  Denmark.  Mental 
disease,  paranoid  form  of  dementia  from  tumor  of  the  brain.  The  patient  had  fixed  delusions 
of  grandeur  and  of  persecution;  irritable;  quarrelsome:  finally  she  became  much  demented. 
She  finally  developed  spastic  paralysis  of  right  arm  and  leg;  reflexes  exaggerated:  right  pupil 
responded  sluggishly  to  light;  retinae  normal.  She  had  no  convulsions,  no  headache  nor 
vomiting,  and  there  was  no  evidence  of  optic  neuritis. 

An  operation  for  relief  of  pressure  upon  the  motor  area,  of  left  side  was  performed.  Intra- 
cranial pressure  was  found,  but  no  growth  presented  at  the  seat  of  operation,  and  the  wound 
was  closed.  Twenty-four  days  after  the  operation  the  patient  died,  and  a  tumor  was  found 
at  the  autopsy,  just  above  the  site  of  the  opening  in  the  skull. 

Skull  thick  and  dense:  shape  symmetrical:  sutures  normal.  Dura  was  abnormally 
adherent  around  the  opening  in  the  skull  and  at  the  vertex. 

Brain:  Weight  of  the  left  hemiencephalon  with  the  tumor,  760  grams;  after  removal  of 
the  tumor,  690  grams:  weight  of  the  tumor,  70  grams;  the  right  hemiencephalon  weighed  610 
grams,  being  considerably  less  in  weight  than  the  left. 

The  tumor,  evidently  originating  in  the  dura,  had  penetrated  the  left  hemisphere,  carry- 
ing the  pia  mater  with  it,  just  in  advance  of  the  central  fissure.  By  its  growth  the  central 
gyri  were  greatly  displaced  backward  and  the  precentral  gyrus  was  greatly  thinned.  The  tumor 
was  roughly  globular  and  measured  on  an  average  of  about  5.5  centimeters  in  diameter.  On 
opening  the  sinus  a  mass  of  the  growth  was  found  lying  within  it,  thereby  causing  obstruction 
to  the  blood  current  and  thrombosis.  The  tumor  was  believed  to  be  a  spindle-celled  endothelial 
sarcoma  of  the  dura — a.  decision  afterwards  verified  by  the  microscope. 

The  lungs  showed  broncho-pneumonia  with  slight  pleuritis.  The  kidneys  were  moder- 
ately granular  and  contracted.  The  uterus  contained  a  few  small  leiomyoniata.  Other  organs 
showed  nothing  important. 

Superior  view  of  the  same  brain  showing  the  tumor  in  situ.  A  small  portion  of  the  dura 
is  adherent  to  the  tumor,  the  sinus  is  opened,  and  the  small  mass  of  the  tumor  is  seen  within 
it.  The  ragged  area  on  the  border  of  the  left  convexity  is  the  mutilated  surface  of  the  brain, 
which  was  adherent  to  the  overlying  dura  and  scalp. 

An  additional  illustration  of  this  case  is  given  on  Plate  LXXIA  . 

(150) 


GROSS   MORBID  ANATOMY  OF  THE  BRAIN   IN   THE   INSANE. 


PLATE   LXXIIL 


PLATE    SHOWING    A    TUMOR    OF    THE    DURA    PENETRATING    THE    BRAIN. 


PLATE    LXXIV. 


(151) 

4  TUTS— 08 20 


PLATE  LXXIV. 

Autopsy  No.  2113a. 

mesial  sxtrface  of  the  left  hemiencephalon,  showing  cavity  left  ix  the  brain  after 
enucleation  of  the  tumor  of  the  dura  shown  on  plate  lxxiii. 

Case  9119.  Showing  the  cavity  left  in  the  brain  after  enucleation  of  the  tumor.  The  thin 
edges  of  the  brain  cavity,  the  engorged  veins,  and  the  lateral  bulging  of  the  brain  beneath  the 
falx  are  well  shown.  At  the  upper  right  of  the  plate  is  the  tumor  with  its  adherent  dura.  The 
sinus  is  kept  open  by  two  small  slips  of  wood  to  show  the  tumor  mass  within  it. 

A  general  discussion  of  this  case  is  given  on  page  150. 

(152) 


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v153j 


PLATE  LXXV. 

Autopsy  No.  2011. 

tumor  of  the  dura  penetrating  the  brain. 

Case  14527.  J.  W.;  aged  36;  female;  colored;  nativity.  United  States.  Mental  disease, 
dementia  from  intracranial  tumor. 

The  case  was  reported  in  the  New  York  Medical  Journal,  April  7,  1906. 

The  picture  here  introduced  is  a  basal  view  of  the  right  hemisphere  with  the  tumor  in  sifu. 
The  extent  to  which  it  invaded  the  opposite  hemisphere  is  seen  by  the  prominence  beyond  the 
median  line.  It  was  to  a  greater  degree  embedded  in  the  right  side,  and  the  size  of  the  growth 
and  the  displacement  of  the  normal  structures  are  well  shown.  The  tumor  was  approximately 
8  centimeters  in  diameter,  was  roughly  spherical  in  shape,  and  weighed  when  enucleated  140 
grams  (nearly  5  ounces  avoirdupois).  Microscopic  examination  showed  the  growth  to  be  a 
spindle-celled  endothelial  sarcoma,  probably  of  dural  origin. 

(154) 

o 


GROSS  MORBID  ANATOMY  OF  THE  BRAIN   IN  THE   INSANE. 


PLATE  LXXV. 


TUMOR    OF    THE    DURA     PENETRATING    THE    BRAIN. 


UNIVERSITY  OF  CATJFO  *  T*T 


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